A us*: oltation and Percussioi 



Kv ,a>i 



LIBRARY OF CONGRESS. 

" Shelf .4-3.5" S 

UNITED STATES OF AMERICA. 



AUSCULTATION 



— AND — 



PERCUSSION. 



FREDERICK C. SHATTUCK, M.D., 

Professor of Clinical Medicine in Harvard University; Visiting 
Physician Massachusetts General Hospital, etc. 



fa 



\/ 




1890. 
GEORGE S. DAVIS, 

DETROIT, MICH. 



'FEB 3 1891" 






.s - 



Copyrighted by 
GEORGE S. DAVIS. 

1890. 



TABLE OF CONTENTS. 

PART I.— THE LUNGS. 

CHAPTER I. 

Page 
Physical Signs in Health I 

CHAPTER II. 

Physical Signs of Disease n 

CHAPTER III. 

The Physical Conditions and Diseases of the Pleurae and 

Lungs 28 

PART II. -HEART AND AORTA. 

CHAPTER I. 
The Heart in Health 57 

CHAPTER II. 
The Heart in Disease 64 

CHAPTER III. 
The Pericardium 100 

CHAPTER IV. 
Thoracic Aneurism 106 

CHAPTER V. 

Physical Exploration of the Liver, Spleen, Stomach and 

Pancreas 113 



INTRODUCTION. 

The primary object of the physical examination of the 
chest is the attainment of a knowledge of the physical condi- 
tion of the important organs contained within it. Not until 
this knowledge has been obtained are we in a position to de- 
termine with all possible accuracy the cause or causes which 
have led to, or which underlie, those deviations from the 
normal physical condition revealed to us by the methods 
about to be described. Essentially the same physical con- 
dition may be encountered in widely different diseases — i. 
e\, as the result of quite different causes — to discriminate be- 
tween which the family and previous history of the patient; 
the influences to which he has been exposed; the symptoms 
which he presents, with their mode of onset, progress, and 
sequence; a careful examination of the patient as a whole, of 
his other organs or systems of organs; and, finally, a 
thorough knowledge of the natural history of general and 
local morbid processes; must all likewise be duly noted and 
weighed. In a word, percussion and auscultation — the two 
chief modes of thoracic physical exploration — lead directly to 
the detection of diseased conditions, only indirectly to that 
of diseases. 

Health precedes disease; it is, therefore, incumbent on 
us to master healthy conditions first. Perfect familiarity 
with the anatomy of the healthy chest and its contents, with 
the structure of each separately and the mutual relations of 
all is of vital importance. Furthermore, the variations of 
size and relation within the limits of health which may occur 
in the same person at different periods of life or under differ - 
ent conditions — as in activity and repose — as well as the 
limits of normal variation in different persons, must be 



VIII 

known. Finally, the physiology of respiration and circula- 
tion must be thoroughly understood. The possession of 
most of this knowledge is here presupposed, inasmuch as 
this series of Manuals is intended rather for physicians than 
for younger students. We may, consequently, now go on to 
consider the special methods of physical exploration and the 
results which they may be made to yield in health and dis- 
ease. At the same time the accompanying plates, after 
Weil, may serve to refresh the memory as to the space 
occupied by the thoracicviscera and their mutual relations. 
These methods in the order in which they should be 
practiced are : Inspection, Palpation, Mensuration, Percus- 
sion, Auscultation, Succussion. 



PLATE I. 




Anatomical Borders— Anterior View. (Weil). 



A B Border of the right pleural sac 

C D Border of the left pleural sac. 

E F Edge of the right lung. 

G H Edge of the left lung. 

| Upper incisura interlobular^ of the right lung. 

K Lower incisura interlobularis of the right lung. 

L Left incisura interlobularis. 

M N Right border of the heart. 

N O Lower border of the heart. 

P O Left border of the heart. 



Sinus znediastinocostalis, situated between the 
edge of the pleura and incisura cardiaca of the 
anterior border of the left lung. 

Highest point of the portion of liver covered by 
lung. 

Lower edge of the liver. 

Cardiac portion of the stomach. 

Pyloric portion of the stomach. 

Small curvature of the stomach. 



W Greater curvature of the stomach. 



PLATE II. 




Anatomical Borders on Left Side. (Weil). 



A B Lower border of the left long. 

A C Lower boundary of the pleura. 

D E Incisura interlobularis. 

F Edge of the left lobe of the liver. 



H G Anterior and posterior ends of the spleen. 
K Kidney. 
N Stomach in moderate distention. 



PLATE III. 






■'•>. 



E . /^ 



^s 



v 





Anatomical Borders—Posterior View. (Weil). 

A B Lower borders of the lungs. H Spleen. 

C D Lower borders of the pleurae. ! Lower border of the liver. 

E F Incisures interlohnlares. K L Kidneys. 

Q Point where the right incisura divides into the sulc, interlob., dext, super., and infer. 



PLATE IV. 



a& 





Percussion Borders in Middle Age. (Weijl). 



A B C D Area of cardiac flatness. 

A I K Area of cardiac dulness. 

C E Lower border of right lung. 

D F Lower border of left lung. 



G H Upper borders of lungs. 
P Q Upper border of hepatic dulness. 
L M Lower border of hepatic flatness. 
N O Lower border of stomach in moderate disten- 
tion. 






PLATE V. 







Percussion Borders on Left Side. (Weil). 



A B Lower border of hepatic flatness. 
C D Lower border of left lung. 



E I L Splenic dullness. 

Q Lower border of stomach. 



PLATE VI. 




Mi 



Percussion Borders on Right Side. (Weil). 

A B Lower border of the right lung. C D Lower border of hepatic flatness. 

E F Upper border of hepatic dullness. 



PLATE VII. 



.<*?■ 







BBSS 






h 


'6, 


Y 


^ 




%^ I 




';$%■■ 




-Zl_iO ' ■::< 





Percussion Borders on the Back. (Weil). 



A B Upper border of lungs. 

C D Lower border of longs. 

E H Lower border of spleen. 

K F Lower border of hepatic flatness. 



H I K L Outer borders of the so-called renal dullness. 
M N Lower borders of the lungs in deepest inspira- 
tion. 
O P Shrinkage of upper border of lung in phthisis. 



PART I -THE LUNGS. 



CHAPTER I. 

PHYSICAL SIGNS IN HEALTH. 

i. Inspection. — The patient should stand at 
ease, stripped to the waist, with the heels together and 
the weight equally borne on both feet, facing the 
light. If he is confined to the bed, or unable to sit 
up, similar precautions should be observed; the aim 
being to avoid the artificial production of any dis- 
parity between the two sides of the chest. 

The facies of the patient, his general nutrition 
and muscular development, cyanosis and oedema or 
their absence, are to be noted; also the size, form, and 
symmetry of his chest; the rate and character of his 
breathing, both as a whole and relatively on the two 
sides; the seat and character of the cardiac move- 
ments, and their area of distribution; the presence or 
absence of abnormal pulsations in the chest or neck, 
and arterial trunks of the upper extremities. 

2. Palpation. — The chief application of this 
method of examination is in confirmation of the re- 
sults of auscultation. The vibrations of the voice are 
in most men transmitted to the chest walls unless this 



is covered by a thick fat layer; in women and children 
they are often not so transmitted unless the voice 
be raised as in singing or crying. The tension of the 
chest wall has an important influence on the trans- 
mission of vibrations originating in the lungs or 
upper air passages to the parietes; thus the tactile 
vocal fremitus is more marked, other things being 
equal, if the wall is relatively tense than if it is rela- 
tively lax. Palpation is also of service in localizing 
the apex of the heart. 

3. Mensuration is less used than any of the 
other methods except succussion; it may be made 
to yield information as to the extent of respiratory 
excursion of either or both sides, and symmetry or de- 
viations therefrom may be more accurately deter- 
mined by the stethometer than by the unaided eye. 

4. Percussion. — This important method of ex- 
amination is best practiced simply with the fingers; a 
great variety of hammers and pleximeters has been 
devised, but they have no notable advantages over 
the fingers in ordinary clinical work. It is possible 
for one who percusses very much to excite periostitis 
of the phalanx used as a pleximeter; and, in class de- 
monstration, louder sounds can be elicited by many 
through artificial than through natural means. 

To obtain satisfactory results certain precautions 
are absolutely necessary, and some practice is needed 
to acquire a good technique. The finger which is 
struck should be firmly and accurately applied to the 



— 3 ~ 
part, and the striking finger should deliver a perpen- 
dicular and quick blow, not remaining in contact with 
the other. The manner in which the hammer of a 
piano strikes the wire may be regarded as the type of 
percussion. Forcible percussion is rarely necessary 
or desirable. A gentle blow properly delivered yields 
a better note, does not hurt or alarm the patient, es- 
pecially important in children, and elicits the note 
belonging to the part struck. A hard blow tends to 
set more or less distant parts in vibration, particularly 
if the chest wall is thin and elastic. In determining 
the line of separation between a solid and an air-con- 
taining body, far better results are obtained by gentle 
than by forcible percussion. The idea of many au- 
thorities, that the dullness of a deep-lying solid body 
is best brought out by hard percussion, is believed 
by the writer to be fallacious. It is to be remembered 
that there is no absolute standard of resonance to 
which all chests must conform. Speaking broadly, 
each person furnishes his own standard. Consequently 
similar points on the two sides should ordinarily be 
struck successively and with equal force. Percussion 
should usually also be in straight lines, especially 
when it is desired to map out accurately a dull area. 
Finally, the lessons of the regional anatomy of the 
chest are to be borne in mind, and one standard is 
not to be applied to the chest as a whole. Percussion 
results which are normal in one portion of the thorax 
are abnormal in another. 



Percussion is either non-resonant or resonant. 
Non-resonance is termed flatness, and signifies the 
entire absence of air in the part struck. Dullness is 
a relative term, and denotes diminished resonance. 
Resonance implies the presence of air, differs greatly 
in degree, and, as encountered in the chest, also 
differs in kind. It is, consequently, desirable to 
analyze resonance in order that we may be the better 
able to appreciate its shades and modifications. The 
elements into which resonance may be resolved are 
intensity, pitch, quality, and duration. 

Intensity denotes simply the loudness of the note,, 
and may be made to vary with the force of the blow 
and the skill with which it is given. The thinner and 
more elastic the chest wall, the larger the amount of 
air, and the thicker the layer of tissue containing it 
beneath the part struck, other things being equal, the 
greater the intensity of the note. 

Pitch also varies in different normal chests, and 
in different parts of the same chest. We speak of it 
as being either high or low. It is relatively low over 
healthy lung, and is apt to rise with diminution in in- 
tensity or change in quality. A well-trained musical 
ear is an advantage in the detection of shades of 
pitch, but is not absolutely necessary. 

Quality is that which gives to the sound its pecu- 
liar character and chiefly distinguishes one sound from 
another. In physical examination we meet with only 
two qualities — the vesicular, that which is produced 



— 5 — 
by percussion over normal lung; and the tympanitic, 
produced over relatively large bodies of air, as in the 
stomach or intestine. The quality is more or less 
marked in different persons and in different parts of 
the same persons, in accordance with obvious laws, 
A pure tympanitic note is rarely met with over the 
healthy chest; but a mixture of the two qualities is 
not very rare, and is termed, after Flint, vesiculo- 
tympanitic. This mixed note is heard in health 
chiefly over the trachea and primary bronchi, and 
over the chest of a child which has temporarily some- 
what over-distended its lungs by crying. When any 
doubt is felt as to the quality of a note, it is well to 
seek out typical notes of the two qualities, which can 
nearly always be found somewhere in the chest or 
abdomen, even of those with advanced disease. In- 
tensity and quality are in no way related; but low 
pitch and vesicular quality are closely associated. 

The Duration of the note is nearly related to the 
pitch, and is, by an unmusical ear, sometimes more 
easily appreciated than is the latter. The higher the 
pitch, the shorter the note. 

In percussing, it is also well to note the sense of 
resistance under the finger; the more solid and less 
elastic the part percussed, the greater is the resist- 
ance. 

5. Auscultation. — This is spoken of as imme- 
diate when practiced with the ear applied to the chest 
wall, with or without the intervention of a towel or 



clothing; mediate when a stethoscope is used. The 
former is a rougher method, but, especially when the 
e&r is held to the naked skin, may be made to yield 
valuable results. A dirty patient and the female sex 
preclude this method to a certain extent; but imme- 
diate bears somewhat the same relation to mediate 
auscultation that the low does to the high power of 
the microscope. A good auscultator is not depend- 
ent on the stethoscope, which, however, apart from 
its convenience and aesthetic qualities, is of great 
value in bringing out and localizing fine shades and 
changes. The binaural stethoscope is the best, and 
that which is generally used in this country; but the 
straight instrument is the more convenient to carry 
about and one should be able to use all kinds. 

The breath sounds vary not only in different per- 
sons but also in the same person; in the latter case to 
a less extent comparatively on the two sides, to a 
greater extent in different regions of the chest. As 
in percussion, so here each person must furnish his 
own standard to some degree, and similar points on 
the two sides should, as a rule, be successively ex 
amined. 

The sounds produced in ordinary superficia 
respiration are apt to be so feeble that we wish to in- 
duce forced breathing in order to intensify them. But 
care must be exercised that in forcing the breathing 
we do not alter its rhythm, and much patience must 
often be practiced to attain this result, the ausculta- 



tor illustrating the desired method himself. Remem- 
ber that expiration is normally a passive act; patients 
must be taught to let go, not to expire forcibly. 

Auscultation enables us to study the sounds pro- 
duced by the air entering and leaving the air pas- 
sages from the larynx to the base of the chest, and 
also those produced by the voice, spoken and 
whispered. These sounds are quite different as heard 
over the trachea and over a distant portion of the 
lung. Over the former we hear normally a kind of 
respiration— called bronchial — which may serve as a 
type of a respiration often heard in abnormal condi- 
tions over the lungs themselves. But, before going 
further, we must analyze the respiratory murmur. 
We divide it in the first place into the inspiratory and 
expiratory acts; and each of these acts is then studied 
with reference to intensity, pitch, and quality; the 
relative duration of the two, or the rhythm, being also 
noted. 

Tracheal Respiration, — Inspiration is of variable, 
but generally marked, intensity, high pitch, and bron- 
chial or tubular quality. Expiration is also of vari- 
able, but usually rather greater, intensity, high pitch, 
and tubular quality; both sounds are long, expiration 
somewhat the longer of the two, and they are separ- 
ated by a slight pause. 

Tracheal Voice-sounds. — These are intense, con- 
centrated, with marked resonance and fremitus. 

Pulmonary Respiration. — To listen to this in its 



typical form one should select a point as far removed 
as possible from the trachea and primary bronchi, the 
lower back, for instance. By bearing in mind the 
broad principle that the nearer we approach these 
large tubes the more bronchial in quality does the 
respiration normally become, much confusion may be 
avoided. As in percussion, so in auscultation, we 
have to deal with practically only two qualities; the 
vesicular, that which is proper to healthy lung tissue; 
and the bronchial, such as is heard normally over the 
trachea and, in pathological conditions of the chest, 
is especially characteristic of condensation of the 
lung. As we shall see later, there are sub-varieties of 
bronchial respiration which are usually pathological. 
Mixed respiration, called broncho-vesicular, is also 
frequently heard; in health over and near the trachea 
and large bronchi in front and behind, in various 
situations in disease. There is normally a disparity 
between the two sides of the chest, especially in the 
upper portions; the murmur being less purely ves- 
icular over the right apex — and, indeed, over the 
whole right upper lobe — than over the left. Fixing 
these principles and facts in mind let us then proceed 
to analyze the vesicular murmur. 

Inspiration is very variable in intensity, age hav- 
ing an important influence; in children it is especially 
loud, and may be somewhat harsh. It is, in general, 
louder the thinner and more elastic the chest wall. 
It should be always remembered that intensity is in 



— 9 — 
no way distinctive; marked feebleness may go with a 
purely bronchial as well as with a purely vesicular 
quality. This is a stumbling-block to many students. 
The pitch is low; the quality soft and breezy — vesicu- 
lar; the duration is nearly as long as the inspiratory 
act, which is immediately followed by : — 

Expiration. The sound produced by this act is 
often inaudible, especially at points far removed from 
the large tubes and in highly developed lungs; when 
heard, it is of variable but relatively slight intensity, 
still lower in pitch than inspiration, rather blowing in 
character, of short duration— often not more than a 
fifth as long as inspiration. 

The Thoracic Voice- Sounds vary in different parts 
of the chest along the same lines as the breath-sounds, 
and in different persons, much as does the tactile vocal 
fremitus. The voice, whether spoken or whispered, 
produces, as a rule, but little effect in women, and 
also in children, unless they cry. Indeed, in children, 
diagnosis must often rest largely upon the ausculta- 
tory phenomena of crying. 

Over a thick layer of normal lung the loud voice 
is appreciated as a distant and diffuse resonance and 
fremitus, and it is difficult or impossible to distinguish 
the spoken words; the nearer we approach the large 
tubes the more intense and concentrated are the 
sounds. The whispered voice corresponds in most 
cases to a forced expiration; is inaudible, or very 
faint and distant, over the lower portions of the chest, 



IO 



becoming louder, more concentrated, and of higher 
pitch, near the large bronchi. It is often of great 
value to study the whispered voice for diagnostic pur- 
poses. 



CHAPTER II. 

PHYSICAL SIGNS OF DISEASE. 

i. Inspection. — Too much importance is not to 
be attached to changes in form and symmetry, especi- 
ally if these are slight. The long shallow chest, with 
wide intercostal spaces, vertical sternum, and feeble 
muscular development — the paralytic thorax — is not 
so suggestive of phthisis as was formerly supposed. 
The barrel-shaped thorax which moves as one piece 
in respiration, has been so much and so carefully de- 
scribed as to lead many students to believe its absence 
excludes emphysema — a serious error. Marked ex- 
amples of this form of chest are, at least in the experi- 
ence of the writer, not common. Its presence is more 
distinctive than its absence, and the superficial appear- 
ance varies a good deal with the amount of fat and 
muscle covering its owner. In thin persons the prom- 
inence of the accessory muscles of respiration, and 
the rounded high shoulders, are striking; in the well 
nourished, one notes the shortness of the neck, depth 
and shortness of the thorax as a whole, the slowness 
of movement, and the turgescence of the general in- 
tegument. The pigeon-breast in its several varieties 
is always characterized by flattening of the sides, with 
prominence of the sternum and also, perhaps, of the 
upper costal cartilages; it is in the angle formed by the 



12 



sternum and the cartilages that the essence of the 
variations usually lies. This form of chest is suggest- 
ive of rickets, with which severe bronchitis and atelec- 
tasis, or broncho-pneumonia, were probably associated, 
in early life. It throws light on the previous history 
rather than on the present condition. The distortion 
of the chest due to angular spinal curvature may be 
very great, and lateral curvature may, primarily, cause 
a great disparity in the two sides. But lateral curva- 
ture is often secondary to such affections as chronic 
pleurisy or fibroid phthisis, which seriously cripple 
one lung; in these cases the contraction of the side 
with close approximation of the ribs, the droop of the 
corresponding shoulder, and the double curve of the 
vertebral column, at once strike the eye. 

A quickened or labored respiration shows either 
that emotional causes are at work, or that blood- 
aeration is accomplished with difficulty or imperfect- 
ly; if imperfectly, cyanosis is also present to a greater 
or less degree. A disparity between the movements 
of the two sides, seen better when the respiration is 
forced, indicates that the expansion of one lung is 
more or less interfered with from some cause, and 
that the cause is, at least mainly, unilateral. The eye, 
too, often puts the careful observer on the track of 
modifications in the circulatory apparatus, and even 
may suggest a shrewd guess as to their nature. 

2. Palpation and Mensuration call for no 
extended remarks here. Of the two palpation is far 



— 13 — 
the more important, enabling us to confirm or reject 
suspicions of unilateral or local increase or decrease 
in the transmission of vibrations from the larynx to 
the chest wall; often to appreciate with the hand the 
presence of secretion in the larger bronchial tubes, or 
of roughening of a serous membrane; and yielding 
valuable information as to the seat, character, and 
rhythm of abnormal pulsations in the neck, chest, 
abdomen, and peripheral vessels. 

3. Percussion. — As the physical condition of 
the chest or its contents becomes altered by disease or 
accident, the percussion note proper to the affected 
individual is frequently changed, either over the 
thorax as a whole or locally, according as the 
changes are general or circumscribed. The intensity 
of the note, other things being equal, is proportional 
to the amount of air beneath the part struck and the 
thickness of the layer of tissue containing it. The 
quality of the note, on the other hand, is, speaking 
broadly, rather indicative of the manner in which the 
air is held in the part. Flatness, absence of reson- 
ance, means absence of air, and is not found normally 
above the diaphragm except on very gentle percus- 
sion over a limited area near the heart's apex, the 
superficial cardiac space. But dullness — diminished 
resonance — is a purely relative term, and may ap- 
proach closely to flatness on the one hand, or deviate 
very little from the normal resonance of the part on 
the other. It is indicative of a diminution from one 



— 14 — 

or more of many causes of the proper amount of air 
beneath the part percussed, or of an increase in the 
solids, or of both; and is, consequently, associated with 
a great variety of conditions and diseases. According 
to its degree and the skill of the examiner, dullness 
is very easy or very difficult of appreciation. If the 
note is dull the intensity is less, the pitch higher, and 
the duration shorter; the quality may remain vesicu- 
lar, though of less intensity, or it may lose entirely 
its vesicular quality and become tympanitic; in other 
words, dullness does not determine quality. 

Any resonance which is non-vesicular must nec- 
essarily be tympanitic; but the two qualities may be 
mixed, giving rise to the note called vesiculotympan- 
itic. As has been already stated, there are regions of 
the normal chest over which this combined note is 
often found; elsewhere, however, it is apt to be a sign 
of some deviation from perfect health. 1 he pitch 
rises as the tympanitic element comes to the fore. A 
pure tympanitic resonance over the chest or a part 
thereof is practically always indicative of an abnormal 
condition, whether it arises within the thorax or is 
conducted from without — the hollow abdominal vis- 
cera. It is the quality which is especially distinctive 
of tympanitic resonance; the intensity may be great 
or slight; the pitch varies, but is usually higher than 
normal vesicular resonance. There are two sub-varie- 
ties of the tympanitic resonance, the cracked-pot and 
the amphoric. The former can be imitated by clasp- 



— is — 

ing the hands together, palm to palm, in such a way 
as to leave between them an air space communicating 
in one direction with the outside air, and then by 
striking the back of the under hand sharply against 
the thigh; the air between the thumbs is thus forcibly 
compressed and produces a "chink" in its escape un- 
der pressure through the narrow opening. To elicit 
this sign tolerably forcible percussion is often re- 
quired, and it may be necessary to hold the ear or the 
chest-piece of the stethoscope near the open mouth of 
the patient. If the chest is very elastic or the lungs 
are somewhat over distended with air, both of which 
conditions may be filled in a crying child, this sign 
may be met with in a healthy chest. It is, however, 
commonly heard only over a relatively large air-space, 
as, for instance, over a pulmonary cavity, but is also 
sometimes heard in pleurisy and pneumonia; in the 
former over the condensed lung just above the level 
of the fluid, in the latter in the immediate vicinity of 
complete consolidation. The illustration given above 
affords a hint as to the mechanism of its production. 
A sound closely resembling the cracked-pot, and 
liable to lead to error, may arise on a hairy chest, as 
well as on a chest which is not hairy if the pleximeter 
is not accurately applied to the skin. These sources 
of error are far more common if artificial pleximeters 
are used. Wetting the hair and a careful technique 
will eliminate them. Amphoric resonance is that 
which is obtained by striking on an empty cask or 



— 16 — 

pitcher, and may be imitated by percussing the cheek 
distended with air, while percussion on the undis- 
tended cheek gives rise to a simple tympanitic note. 
Amphoric as contrasted with tympanitic notes are 
metallic, and are followed by a metallic echo^ which 
prolongs their duration and raises their pitch. Even 
more than the cracked-pot, this sound is indicative of 
a large air space such as is furnished in the chest only 
by lung cavities or by air in the pleural sac. But 
other conditions are needed; the cavity must be, ac- 
cording to Wintrich, at least six centimeters in the 
direction in which the force is applied; and it must 
also be superficial, bounded by homogeneous walls, 
free from an excess of fluid contents, and covered by 
a chest-wall thin enough not to be too resistant. If 
the cavity communicates with a large bronchus, the 
note is intensified by opening the mouth, but such 
communication is not necessary for its production. It 
is, therefore, seen that while the presence of this sign 
is very distinctive, its absence is very far from exclud- 
ing cavity formation. It is over the upper fronts that 
the conditions for the production of the cracked-pot 
and amphoric notes are usually met; the former is 
rarely, if ever, found over the lower lobes, the latter 
in this situation only in cases of pneumo-thorax. 

4. Auscultation. — The auscultatory signs of 
disease fall into two main classes; those in which the 
breath and voice sounds, one or both, are changed 
from those proper to the person and the part in 



— 17 — 

health; and those sounds called " adventitious," not 
heard at all in perfect health. The change of the first 
class are as follows: 

Vesicular Respiration may be increased in intensity 
without any change of pitch or quality, and is then 
often called supplementary or puerile; supplementary 
because when heard in adults it indicates that the 
part over which it is heard is doing extra or supple- 
mentary work; puerile because it resembles the re- 
spiratory murmur normally heard over the chest of a 
child. It is not an uncommon error for students to 
mistake puerile for bronchial respiration, an error 
easily avoided by paying careful attention to the 
pitch. It may perhaps be stated here as well as else- 
where, that when one is in doubt as to the quality of 
respiration it is often well to study the type qualities, 
the bronchial over the trachea, while the vesicular 
can usually be found at some portion of even the 
most diseased chest. By comparing the doubtful re- 
spiration with the types its true characteristic can 
generally be made out. 

Diminished intensity is incident to a great variety 
of conditions. In simple diminution the quality re- 
mains vesicular or, from very feebleness, cannot be 
determined. The sign may be due to any affection 
of the chest wall, the diaphragm, or the abdomen and 
its contents which, often by involving pain, induces 
shallow respiration; to thickening of or slight ac- 
cumulation in the pleura; to any morbid condition of 



— 18 — 

the lung tissue involving deficient aeration of the part; 
to affections of the bronchial mucous membrane and 
the lodgment of foreign bodies; to the pressure of 
tumors in the lungs, larger bronchi, or upper air-pas- 
sages, and the like. 

Absence or suppression of the respiratory murmur, 
as will be readily understood, occurs under much the 
same conditions as simple enfeeblement; but denotes 
that these have reached a higher degree. 

Bronchial Respiration is to be heard in the 
healthy body only over the trachea and larynx, or in 
the region of the malar bone, and its characters can 
here always be studied; it is, however, to be remem- 
bered that the murmur seldom, if ever, is as intense 
over the chest as in the above mentioned localities. 
It is not necessary to repeat here the analysis of this 
variety of respiration. The sign indicates consolida- 
tion of the lung of a certain extent and at or not too 
far removed from the outer surface. In cases of 
pleural accumulation, or of more or less central con- 
solidation, the sound may convey the impression to 
the ear of coming from a distance. As to the nature 
of the solidification the sound in itself affords no in- 
formation. The sign is sometimes incomplete in that 
only one of the respiratory acts may be audible, more 
frequently inspiration. Its suggestiveness is not, 
however, lessened thereby. Or, again, inspiration 
may be vesicular but expiration bronchial, the latter 
being more intense and consequently further trans- 
mitted. 



— i 9 — 

Broncho- Vesicular Respiration is heard in many 
healthy chests about the apices of the lungs and near 
the primary bronchi in front and behind. As the 
name indicates it implies a combination of the bron- 
chial and vesicular qualities, either of which may pre- 
dominate in any given case. It is called by some 
rude or harsh respiration. In proportion as the bron- 
chial element is marked the pitch of both acts rises 
and expiration increases in length. The sign denotes 
partial solidification of lung, a degree not sufficient to 
produce bronchial respiration. It will be readily un- 
derstood that there is room here for wide variation 
and nice shades of difference. According to the ex- 
tent and completeness of the consolidation, its prox- 
imity to the chest wall, the thickness of this medium, 
and other factors, the bronchial element is more or 
less well marked and easy of recognition. It is some- 
times only after taking into consideration the other 
physical signs that one can rightly estimate this form 
of respiratory murmur. Once more the fact must be 
alluded to that respiration over the right apex is 
normally less vesicular, or more broncho-vesicular, 
than over the left. 

The cavernous respiration of Flint and its modi- 
fications are not sufficiently common or important to 
require description in a book of this size. 

Amphoric Respiration, however, is a sub-division 
of the bronchial which is so distinctive and peculiar 
as to merit brief mention. Its character is precisely 



20 

that which belongs to the sound produced by blowing 
into a somewhat narrow necked and, at least par- 
tially, empty vessel; and that which especially stamps 
it is the metallic echo and musical sound which 
accompanies and follows the bronchial quality. It 
may be heard in both respiratory acts or in one only; 
if only in one more commonly in expiration. When 
heard it is absolute proof of the presence of a large 
cavity with walls of uniform density and in free com- 
munication with the bronchial tract, whether the cav- 
ity be seated in the lung or outside of it. In the 
former case its favorite seat is the upper front, in the 
latter the lower and middle regions of the chest. If 
a pulmonary cavity is full of secretion the conditions 
for its production are not fully met, and the sign may, 
consequently, be present at one and absent at the 
next examination, or vice versa. 

Under the head of modifications of rhythm we 
distinguish: 

i. Shortened Inspiration, a sign of deficient aera- 
tion of the part and encountered alike in the opposite 
conditions of partial obliteration and dilatation of the 
air vesicles. To distinguish between the two, pitch 
and quality must be studied. 

2* Prolonged Expiration is, like shortened in- 
spiration, sufficiently described by its name; it in- 
dicates that some kind of impediment to the free 
escape of air from the part exists, and is met with in 
the various degrees of condensation as well as in those 



21 

of dilatation of the lung tissue. In the first case the 
pitch and quality are changed, in the second they are 
not. Here too, the regional anatomy of the chest 
must be remembered and the normal difference be- 
tween the apices. 

3. Interrupted, Jerky, or Cogged-wheel Respiration 
is often due simply to lack of skill or want of training 
in breathing on the part of the patient. It is worthy 
of no special regard when it stands alone, unassoci- 
ated with other signs. 

Adventitious Sounds or Rales, never heard in 
absolutely normal conditions, may originate in any 
portion of the respiratory tract and are often classi- 
fied on the basis of their seat of origin. They are 
also divided into coarse and fine, moist and dry, 
according to the notion conveyed to the ear as to 
their mode of production. They arise either within 
the air passages or in the pleura, and are due in the 
former situation to narrowing of the tubes from swell- 
ing of the mucous membrane, spasm, pressure from 
without, or similar cause, or to the presence of mucus, 
pus, blood, serum, fibrin, and other abnormal matters 
in the respiratory tract; in the latter to roughening or 
partial agglutination of the pleural surfaces. 

Tracheal rales are usually audible without the 
stethoscope; of the moist ones the death rattle is most 
typical; the dry ones are suggestive of stenosis frorti 
whatever cause and produce a respiration termed 
stridulous or, simply, stridor. 



22 — 

The moist bronchial rales are bubbling in charac- 
ter and vary in size with that of the tubes within 
which they arise; the dry bronchial rdles are whistling 
— sibilant, — or snoring — sonorous, — and are believed 
to originate only in the larger bronchi; moist rales in- 
dicate the presence of a relatively thin fluid, dry rales 
of partial occlusion from one or more of various 
causes; swelling, constriction, or very tough secretion, 
being the most frequent of these. Bronchitis is the 
chief underlying cause of bronchial rales, the special 
character of which is determined by the character and 
seat of the secretion or swelling, as well as by its ex- 
tent. The finer bronchial rales, however, classed as 
sub-crepitant and arising in the bronchioles, are in- 
cident to many different diseases, as we shall see 
later, though they generally indicate essentially the 
same physical condition, namely, the presence of 
a thinnish fluid. All the bronchial rales may be 
heard in either or both of the respiratory acts. Coarse 
and fine, moist and dry, may be heard in different 
parts of the same chest simultaneously or at brief in- 
tervals of time. It is well to train the ear to note the 
pitch of these and other adventitious sounds as they 
sometimes so obscure the breath sounds that the char- 
acter of the latter cannot be determined. Lung con- 
solidation may be betrayed by high pitched and more 
or less intensely loud rales when the respiratory mur- 
mur cannot be heard. These are the consonating 
rales of Skoda. 



— 23 — 

The only rale which is believed to arise within 
the air vesicles is the crepitant, the finest of all, uniform 
in size, dry in character, heard only in inspiration, 
sometimes in the latter part of that act alone. It can 
be artificially imitated by rolling the hair near the ear 
between the thumb and finger, among other ways. 
The crepitant rale is especially characteristic of pneu- 
monia in its first and third stages: the first stage fre- 
quently does not come under medical observation, 
and in the third stage the moist sub-crepitant is quite 
as common as the dry crepitant rales, consequently 
there are many cases of pneumonia in which this 
characteristic sound is not heard. It also occurs, es- 
pecially about the apex, in some cases of phthisical 
consolidation. In other conditions it is, to say the 
least, rare. 

Cavities containing liquid and communicating 
with a bronchus, if sufficiently large and near the 
surface, often give rise to rales which are very sug- 
gestive, either by their coarse and bubbling nature 
and their marked intensity, or by their ringing, musi- 
cal, or metallic quality. The latter occurs under 
practically the same conditions as the amphoric per- 
cussion note and respiration. Besides the above men- 
tioned rales which admit of more or less accurate 
classification, others are sometimes met with in the 
chest, especially the apices, which can be character- 
ized as crumpling, creaking, or crackling. In that 
situation they awaken suspicion of phthisis. 



— 24 — 

Before leaving the subject of pulmonary rales, 
one or two remarks are in order. The act of cough- 
ing often has a marked effect on their production, the 
coarser moist rales sometimes promptly disappearing 
as the secretion which caused them is dislodged, the 
finer rales becoming more distinct, or, indeed, appear- 
ing only on cough -forced expiration— or during the 
relatively deep and quick inspiration which must al- 
most necessarily follow it. In cases of suspected 
limited consolidation, especially about the apex and 
of phthisical origin, an examination is not complete 
unless this method is practiced. 

It is not uncommon to hear during the first deep 
inspirations of a person who has been lying on his 
back for some time and breathing superficially, fine 
rales over the lower lobes behind. When heard thus, 
and thus only, they have no pathological significance, 
and are due simply to the unfolding of partially col- 
lapsed lung tissue. 

Finally, one should always be careful not to mis- 
take sounds produced by the rubbing of clothing, or 
of the chest piece of the stethoscope, against the skin 
— very liable to occur if the latter is hairy— for true 
rales. This remark applies to pleural as well as to 
pulmonary adventitious sounds. 

The typical pleural adventitious sound is called 
friction rub, or sound, a term which is highly descrip- 
tive. In health the pleural surfaces glide noiselessly 
over one another; but when they are roughened a 



— 25 — 

sound is produced of extremely variable intensity, 
sometimes scarcely audible to the skilled auscultator, 
occasionally so loud as to be heard by the unaided 
ear at some distance from the chest, often easily felt 
by the hand applied over the part. Pleural friction 
may be heard during either or both acts, is near the 
ear, can sometimes be intensified by pressure with 
the stethoscope, and is apt to be broken or interrupted 
— i. e., not to be continuous throughout the whole of 
inspiration, for instance. When typical, friction can 
hardly be mistaken for anything else except the rub- 
bing of the stethoscope against the skin. 

That sounds indistinguishable from medium and 
fine rales of intra-pulmonary origin may, and fre- 
quently do, arise within the pleura, the writer of this 
little book is strongly inclined to believe, although he 
is not prepared to adopt in full the views of Learning, 
who holds that u all of the smaller rales have an inter- 
pleural origin, and also most of the larger." 

The voice sounds, loud and whispered, in dis- 
ease are well worthy of careful study. As with the 
breath sounds, the changes which they undergo are 
to be regarded rather as modifications of the nor- 
mal sounds than as entirely new sounds, like rales. 
Making due allowances for sex, age, depth of voice, 
and thickness and tension of chest wall, they are 
diminished in intensity, or entirely suppressed under 
all conditions which impair or cut off the transmis- 
sion of vibration from the larynx to the thorax. 



— 26 — 

Thus, if a primary bronchus is occluded they are en- 
tirely absent over the whole corresponding side of 
the chest; if air, fluid, or a solid tumor is interposed 
between the lung and the parietes they are lost or 
diminished over the seat of interposition, in a measure 
largely proportional to the thickness of the interposed 
layer, while they may be markedly increased over 
other portions of the chest. The limits of variation 
extend from the slightest possible decrease to total 
loss. In like manner an increase in resonance and 
fremitus is indicative of a condition facilitating con- 
duction, and such condition is in the great majority of 
cases lung consolidation due to one or more of its 
many causes. Such increase, if more than slight in 
degree, is termed bronchophony, loud or whispered, from 
its identity with the vocal sound normal to the region 
of the tracheal bifurcation, although the type is bet- 
ter derived from the trachea or larynx direct. The 
slight degrees of increase have no special term ap- 
plied to them. &gophony is a peculiar form of 
bronchophony, to which distance from the ear and a 
nasal element resembling the bleating of a goat — 
hence the term — are superadded. It occurs often in 
cases of pleural effusion, moderate in size but suffi- 
cient to permit some condensation of the lung, and 
is heard near the level of the fluid. It is not a sign 
of great importance. Pectoriloquy signifies the dis- 
tinct transmission of the words to the ear of the aus- 
cultator, and is an unimportant subdivision of broncho- 



— 27 — 

phony. Amphoric voice sounds are heard under the 
same conditions as the amphoric breath sound, over 
large pleural or lung cavities in direct connection 
with a bronchus. 

6. Succussion, the last method of physical ex- 
ploration of the chest, never yields results in the 
normal thorax, though such are often obtainable over 
the stomach more or less distended with air and 
liquid. When, in like manner, air and liquid are both 
contained in a large cavity in the chest, as in pneumo- 
hydro-, or pneumo-pyo-thorax, splashing sounds may 
be heard if the patient is shaken or shakes himself; 
the agitation produced by cough may be sufficient to 
give rise to them, and they may or may not have a 
metallic ring. 



CHAPTER III. 

THE PHYSICAL CONDITIONS AND DISEASES OF 
THE PLEUR/t AND LUNGS. 

Inasmuch as physical signs lead directly to the 
detection of conditions, not of diseases, the natural 
order will he followed in treating of pathological 
states of the respiratory organs. 

A. — OF THE PLEURAE. 

i. Roughening of the pleural surface, if acute, is 
apt to give rise to pain, and consequently to a catch- 
ing or superficial respiration, which may or may not 
be accompanied by short, suppressed, or painful 
cough. Respiration being superficial, the murmur is 
feeble, but the distinctive sign is the friction rub, in 
the absence of which, acute dry pleurisy can be surely 
differentiated from pleurodynia and intercostal neu- 
ralgia only by rise of temperature. In subacute and 
chronic conditions, the subjective symptoms are gen- 
erally very slight or absent, and friction is the only 
manifestation. Roughening is usually local, but may 
be diffuse, especially on one side. It may stand 
alone, or play a role (usually a secondary one) in 
connection with a great variety of diseases of consti- 
tutional or local origin. Thus, every inflammatory 
disease of the lung which approaches or reaches the 
surface is almost sure to set up pleurisy. 



— 2 9 — 

2. Thickening, in that it limits the expansion of 
the lung, and also separates it from the chest wall, 
gives rise to characteristic signs. Expansion of the 
affected side is diminished; the side may be shrunken; 
the percussion note is diminished in intensity, as is 
also the respiratory murmur; the tactile vocal fremitus 
and the resonance of the voice are generally not les- 
sened, and may be somewhat increased. Friction 
sounds and pleural rales may or may not be heard, 
according to the density of the adhesions and the 
presence or absence of exudation in their meshes, 
In chronic cases the shoulder of the affected side is 
often decidedly lower than its fellow and there is 
lateral curvature of the spine. 

3. Liquid in the Pleural Cavity may be either free 
or encapsulated, large or trifling in amount, serous, 
sero-fibrinous, purulent, or hemorrhagic in character. 
Encapsulated collections are comparatively rare, and 
the notoriously great variation in the signs of the con- 
dition under consideration depends, in the main, on 
the widely varying amount of the collection. This 
variation makes the comprehension of the subject 
difficult unless one clearly understands the intrathor- 
acic changes which are wrought during the rise and 
decline of an accumulation. The experiments of Gar- 
land would seem to indicate that fluid thrown out into 
the chest is at first moulded by the lung — unless ad- 
hesions complicate matters — and does not compress 
that organ until the retractile force is exhausted; not 



_ 3 o — 

until then, also, can the diaphragm begin to lose the 
upward arch. With the descent of the diaphragm 
descend also the organs which lie immediately beneath 
it, notably the liver, spleen, and stomach. The heart 
swings on the great vessels arising from it as on a 
pivot, and toward the sound side, but never moves as 
far to the left as it may to the right. A moderate- 
sized collection may dislocate the heart, but a decid- 
edly larger amount is required to depress the dia- 
phragm. The lung itself is more or less atelectatic 
in moderate collections, especially near the level of 
the fluid, and is therefore capable of being inflated 
unless adhesions bind it down or there is coexistent 
disease in its tissue. 

(a) The signs of a very small effusion are nearly 
the same as those of simple thickening, except that 
the tactile fremitus and the vocal resonance are 
diminished in the former, while they may be un- 
changed or increased in the latter, false membranes 
often conducting sound fairly well. A distinction be- 
tween the two conditions is not always easy to draw. 
Friction may be heard in both alike. The smallest 
amount of fluid which, in the average adult, can be 
detected with certainty is said to be about twelve 
ounces. 

(6) In moderate collections impaired motion of 
the affected side is seen on inspection, especially with 
deep inspiration; percussion over the fluid is flat if, as 
should always be done, it is practiced gently; and the 



— 3i — 

line of flatness often follows a curved line which is low- 
est near the spine, rising at first sharply and then more 
gradually to the axillary region where it reaches its 
highest point, advancing to the sternum with a slight 
inclination downward. A space, termed by Garland 
" the dull triangle," is enclosed between the ascend- 
ing portion of the curve and the spinal column; per- 
cussion over this space may be flat until the patient 
has deeply inspired several times and thus distended 
this portion of lung. Without this precaution it is 
often impossible to mark out the curved line of flat- 
ness, which is also obscured by adhesions and com- 
plications. Percussion over the relaxed lung above 
the fluid often yields a vesiculotympanitic note, and a 
flat or dull area may clear in a measure with a change 
in the position of the patient, the fluid tending to 
gravitate to the most dependent part of the chest; a 
few minutes must often be allowed for this change in 
the site of the fluid to take place. Displacement of the 
heart is often seen on inspection; but, especially if 
the apex lies under the sternum, the cardiac move- 
ments may not be visible and it is then desirable to 
determine the right border of the heart by percussion 
and the seat of maximum intensity of the first sound 
by auscultation. The breath and voice sounds over 
the fluid are markedly diminished or lost, as is the 
tactile fremitus; at the level of the fluid there may be 
aegophony; over the lung above, an enfeebled but 
broncho-vesicular respiration and increased resonance 



— 32 — 

of the voice are common. Subcrepitant, according to 
some authorities even crepitant, rales may be heard 
over this partially collapsed portion of lung as it un- 
folds with forced inspiration. 

The signs of a decreasing pass through the same 
series of changes as those of an increasing effusion, 
but in an inverse order of sequence. Friction is apt 
to be more marked and more persistent in the declin- 
ing stage, and dulness on percussion, due to pleural 
thickening, may last for a long time. 

(c) In great collections the immobility of the 
affected side is striking, and the side may appear to 
be distended, while the intercostal spaces are flush 
with the ribs. An actual bulging of, or fluctuation in, 
the interspaces is very rare, and denotes a very large 
effusion limited by a thin wall; it is perhaps more 
liable to occur if for any reason space cannot be won 
for the fluid by descent of the diaphragm; it is less 
rare in children than in adults. The cardiac move- 
ments are seen in the left anterior axillary line if the 
right side is affected, over a large area extending 
even beyond the right nipple if the left side is 
affected. The tactile fremitus is lost, and the edge of 
the liver may be felt below the level of the navel with 
right, that of the spleen well below the rib margin with 
left effusions. If the inspiratory force is sufficient to 
inflate the compressed lung somewhat, these organs 
may be felt to descend with the diaphragm. Percus- 
sion is flat with great resistance under the finger over 



— 33 — 
nearly the whole of one side of the chest, more or less 
tympanitic in the front near the primary bronchus. 
The breath sounds are entirely absent, or more or less 
feeble and distant, and bronchial. Occasionally, how- 
ever, bronchial respiration of a surprising intensity is 
heard all over the affected side, rendering it hard to 
believe that the lung is compressed rather than con- 
solidated. This phenomenon seems to depend chiefly 
on the tension of the chest wall and is therefore more 
common in children. Vocal fremitus and resonance 
are usually completely wanting — though the spoken 
words may be very distinctly transmitted to the ear — 
except about the root of the compressed lung where 
there may be bronchophony. The mediastinum may 
be pushed toward the sound side as is demonstrable 
by percussion. Over the healthy lung the resonance 
and breathing are increased in intensity. The degree 
of dyspnoea depends mainly on the rapidity with 
which the collection has taken place. The tolerance 
of a very large effusion which has come on insidi- 
ously and gradually, thus giving time for the system 
to adapt itself to the changed conditions, leads the 
careless to neglect a physical examination and thus 
to overlook a condition which mere inspection of the 
naked chest may diagnosticate with almost absolute 
certainty. 

Fluid in the pleural cavity is usually the result of 
pleurisy, when it is generally unilateral; or of passive 
transudation — hydrothorax — when it is bilateral, 

3 PP 



— 34 — 

sometimes nearly equal, but often markedly different, 
in amount on the two sides. Hydrothorax is, of course, 
not an inflammatory process, and often therefore does 
not involve pleural roughening or adhesions. The 
fluid is thus more free to obey the laws of gravity and 
changes its seat more constantly and rapidly with 
change in the position of the patient; friction too is 
absent. But pleurisy may be secondary to hydrotho- 
rax, causing both adhesion and friction. For hydro- 
thorax a cause is generally found in either the heart 
or kidneys, and there is also dropsy elsewhere. Pleu- 
risy with effusion may complicate many other condi- 
tions, the signs characteristic of each more or less 
obscuring one another. Encapsulated collections of 
fluid are more difficult of detection, but should not 
ordinarily escape a careful examiner. The essence 
of all alike is the separation of the lung from the 
chest-wall by an airless and relatively non-conducting 
medium; the rest is detail. 

The distinctive signs of liquid in the pleural 
cavity are the combination of percussion dullness, im- 
paired transmission of vibrations, and dislocation of 
organs. The first of these is common to lung con- 
solidation; the other two are more characteristic but 
still open to sources of error. In true consolidation 
the transmission of all vibrations may be cut off by 
bronchial occlusion. Dislocation of the heart and 
liver may be simulated by diseases involving enlarge- 
ment of those organs, or by more or less complete 



— 35 — 
congenital transposition of the viscera; while genuine 
dislocation may be caused by new formations, peri- 
cardial effusion, or a retraction of the lung due to 
fibroid phthisis. The latter may be secondary to 
pleurisy attended by marked thickening, the interstitial 
tissue gradually penetrating the lung, condensing and 
destroying its vesicular structure. Again, a large 
effusion may be present without any dislocation, 
adhesions preventing its occurrence. 

While the diagnosis of fluid in the pleural cavity 
generally presents no serious difficulties, and may be 
extremely easy, even uncomplicated cases occur in 
which a positive diagnosis from the combined physical 
and rational signs is of the greatest difficulty. Con- 
solidation of the lung and intrathoracic tumor are 
the two conditions most liable to involve error. The 
latter is as rare as the former is common, but both 
will be more fully considered later. 

In case of doubt, puncture with an irreproachable 
needle will settle alike the presence and nature of 
fluid, the latter not being accurately determinable by 
the ordinary physical signs. (Edema of the chest- 
wall, a jagged temperature chart, to a less degree 
childhood and an African descent, are suggestive of 
empyema. A pulsating pleurisy, almost invariably 
left-sided, is nearly sure to be purulent. An haemor- 
rhagic effusion is far more apt to accompany tubercu- 
losis or cancer than more innocent affections. 

4. Air in the Pleural Cavity is rarely found with- 



- $6 - 

out some important complication. When found, the 
physical condition to which it gives rise is almost 
identical with that arising from liquid in the pleura; 
the main difference is that of the medium separating 
the lung from the throax. This in pneumothorax, 
being air, is resonant; and this air, being enclosed in 
a large space, yields a purely tympanitic or amphoric 
note on percussion. The physical signs other than 
those derived from the percussion note are practically 
the same in the two cases. Pneumo-thorax arises 
from rupture or perforation of the lung, or from per- 
foration—traumatic — of the chest-wall. 

5. Air and Liquid in the Pleural Cavity. — The 
physical condition as regards the lung is, in cases 
without notable complication, the same as in the two 
preceding divisions. It is retracted or compressed, 
unless adherent or consolidated, in proportion to the 
amount of air and liquid just as when only one of 
these is present; the liquid, of course, gravitates to- 
the lower portion of the chest, while the upper is oc- 
cupied by the lighter air. The recognition of the 
condition here again depends chiefly on the results of 
percussion; the note being dull or flat over the liquid, 
tympanitic over the air, and the relative positions of 
the flatness and tympany changing strikingly with 
the position of the patient. The relative proportion 
of the two media varies, of course, widely in different 
cases, somewhat in the same case from time to time. 
Succussion sounds are in the highest degree diagnos- 



— 37 — 
tic. Amphoric respiration denotes that there is a 
perforation of the lung through which the air passes 
to and fro. Metallic tinkling may also be present. 
Pleural adhesions and lung consolidation, if present, 
will modify the signs in ways which are readily under- 
stood, Again, the signs in themselves do not inform 
us whether we have to deal with pneumo-hydro-, or 
pneumo-pyo-thorax. 

B. — OF THE UPPER AIR PASSAGES AND LUNGS. 

i. Of the Larynx and Trachea. The conditions 
which here give rise to the sort of physical signs 
under consideration, are those involving more or less 
obstruction to the free access of air to the lungs; in- 
spiration alone, or both acts, may be impeded; a 
purely expiratory dyspnoea of laryngeal or tracheal 
origin is conceivable, but practically does not occur. 
If the obstruction is of high degree simple inspec- 
tion is fruitful in results; the dyspnoea is great, and 
heightened by the least exertion; cyanosis may be 
marked, the lungs fail to expand, and the soft parts 
above and below the chest, as well as the lower and 
lateral portions of the same, are retracted in inspira- 
tion. The respiratory murmur is weakened propor- 
tionally to the degree of obstruction; the respiration 
is more or less stridulous. If the upper air passages 
are obstructed, the feeble respiration is bilateral; if a 
primary bronchus, it is confined to the affected side, 
while on the other the murmur is exaggerated. 



-3«- 

The diseases giving rise to obstruction of the 
larynx and trachea are, oedema of the glottis, paral- 
ysis of its dilators, spasm, false membranes, tumors 
within or pressing on the parts, foreign bodies. 

2. Of the Bronchi. — (a) Of the Larger Tubes. 
The presence and character of the physical signs 
depend mainly on whether respiration is or is 
not obstructed, partly on the nature of the obstruc- 
tion and its degree. The signs are unilateral if the 
cause be such; as with foreign bodies, the pressure 
of a tumor, aneurismal, glandular, or neoplasmic. Bi- 
lateral conditions are, however, far more common. If 
there be no notable obstruction, physical signs are 
absent, and diagnosis rests on the negative result of 
examination associated with positive symptoms. Ob- 
struction is due generally to swelling, or secretion, 
neither of which can, in this situation, produce dull- 
ness or a change in the voice sounds. They may 
weaken the breath sounds more or less, but do so bi- 
laterally and thus deprive us of the advantage to be 
gained by a comparison of the two sides. Otherwise 
the signs are negative unless swelling causes sibilant 
or sonorous, secretion or other liquid product coarse 
moist rales. By far the most frequent condition 
underlying the condition here described is bronchitis, 
which may or may not, of course, be complicated with 
asthma, emphysema, or lung consolidation. 

(b) Of the Smaller Tubes. It will be readily 
understood that changes do not need to attain such a 



— 39 — 
high degree here to produce physical signs as in tubes 
of large calibre. Obstruction to the free access 
of air to the vesicles may be caused by swelling, 
spasm, liquid products, or compression; involving 
both or only one side of the chest. The distinctive 
signs are: weakening of the respiratory murmur over 
the affected area or areas, and fine moist — sub- 
crepitant — rales if secretion or other liquid is present; 
the rales may entirely obscure the vesicular murmur. 
Notable dyspnoea and cyanosis are seen if the obstruc- 
tion is widespread, and the soft parts above and below 
the chest may exhibit inspiratory retraction; this 
dyspnoea being distinguished from that due to laryn- 
geal and tracheal obstruction by the presence of signs 
in the chest. The number of diseases to which this 
condition is incident is large, including, as it does, 
practically, the very slight degrees and early stages of 
affections involving consolidation of the lung tissue 
to a greater or less extent. Thus it is present in 
many cases of phthisis, especially about foci of active 
inflammation; but the two bilateral affections which 
interest us most here are capillary bronchitis and pul- 
monary oedema. The latter is usually non-inflamma- 
tory, is generally traceable to heart or kidney disease 
and affects by preference the dependent portions of the 
chest; it is, moreover, often accompanied by dullness 
on percussion. The former befalls chiefly the ex- 
tremes of age, and is often fatal, either directly by 
suffocating and exhausting the patient, or by inducing 



— 4Q — 

its dreaded sequels — atelectasis and broncho-pneu- 
monia. These both really involve consolidation, but 
the areas may be so small and so scattered as to give 
rise to no signs distinctive of that condition. The 
recognition of their presence, then, must be a matter 
of inference, chiefly from the symptoms. Fibrinous 
bronchitis may impair resonance and cut off* the 
breath and voice sounds, to a greater or less degree. 
It is rare, and can be diagnosticated with certainty 
only by the expectoration of casts of the bronchi. It 
is, of course, the medium and finer tubes which are 
most liable to be occluded by the fibrinous exudation. 
Before we leave this portion of our subject, a few 
words must be said about Asthma, invariably a symp- 
tom rather than a disease, as is held by some; in its 
pure spasmodic form an independent affection, as is 
held by others. Whether we affirm or deny that 
spasm of the muscular layer of the smaller non-carti- 
laginous bronchi is the cause of the symptoms, that an 
impediment of some nature to the normal to-and-fro 
movement of the air between the larger bronchi and 
the air vesicles exists during the asthmatic paroxysm, 
cannot be disputed. The positive physical signs are: 
Dyspnoea, perhaps cyanosis; a thorax nearly motion- 
less in spite of great efforts, and fixed in the position 
of full inspiration; general hyper-resonance on per- 
cussion; and the universal presence of sibilant and 
sonorous rales masking an enfeebled vesicular mur- 
mur; the breathing is not quickened, but labored — a 



— 41 — 
point of contrast with capillary bronchitis. The signs 
of emphysema, temporary and permanent, will be con- 
sidered later. 

3. Bronchial Dilatation, if sufficient to be recog- 
nized, gives rise to cavitary signs which, in them- 
selves, throw no light on the manner of production of 
the cavity. The signs of cavities belong more ap- 
propriately in another place, but it may be stated here 
that bronchiectasis is more common in the lower 
lobes, and is apt to be accompanied by more or less 
emphysema and solidification. 

4. Dilatation of the Air Vesicles. — This condition 
is associated with but one disease, emphysema of the 
lungs, which may be general or local, temporary or 
permanent. In any case the affected air cells cannot 
be emptied in expiration and there is consequently no 
room for fresh air; or they can be emptied only by 
the aid of unusual respiratory exertion, a difference of 
degree. General temporary emphysema is met with 
in severe pertussis and during the paroxysm of pure 
spasmodic asthma; local temporary emphysema exists 
vicariously in the healthy parts when other and consider- 
able areas of the lungs are thrown out of work. The 
general permanent change is usually associated with 
chronic bronchitis and often with secondary asthma; 
the local w r ith the same conditions as the temporary 
variety but, in this case, of a chronic nature. There 
is, however, a point of essential difference between 
temporary and permanent emphysema; over-distention 



— 42 — 

of the air vesicles is a common factor in both; but in 
the latter the elasticity of the lung tissue is seriously- 
impaired or lost, while in the former it is not. 

The destruction of the pulmonary capillaries and 
the defective interchange of gases throw extra work 
on the right heart which becomes gradually dilated 
and hypertrophied. If compensation fails we get the 
usual signs of general venous stasis. 

The physical signs depend in large measure on 
whether the changes are local or general. The latter, 
being the more characteristic, will be considered 
first. 

Inspection yields results which may be in them- 
selves highly characteristic. In a typical case the 
patient is apt to be pale and somewhat cyanotic, slug- 
gish in his motions and mental processes, slow and 
labored in breathing even while at rest, but far more 
so after the exertion involved in undressing. All the 
diameters of the chest are increased but especially 
the antero-posterior, so that a transverse section, as 
shown by a stethometer, is much rounder than normal 
— the barrel shaped chest. The shoulders are raised 
and rounded, and the clavicles as well as the acces- 
sory muscles of respiration are prominent. The 
thorax is more or less fixed in the position of inspira- 
tion and moves as one piece, especially if the costal 
cartilages are ossified. There may be marked swell- 
ings above the clavicles, visibly increased by cough. 
If there is a thick layer of subcutaneous fat, the tur- 



— 43 — 
gid countenance, hyperaemic conjunctivae, short neck, 
and general form of the chest are still noticeable; but 
the muscular attachments to the clavicles and the dis- 
tinction between the ribs and the interspaces are hid- 
den. It must not be thought that the above described 
form of chest is always present in extensive emphy- 
sema; the affection may be general and far advanced 
in a thorax of the paralytic type. The cardiac im- 
pulse is feeble or wanting in the normal site while 
epigastric pulsation may be marked, the dilated lung 
occupying the space where the heart ought to lie in 
immediate contact with the chest wall, and the right 
ventricle being dilated and hypertrophied. 

Percussion gives exaggerated or vesiculotympan- 
itic resonance as well as an increase in the area of 
pulmonary resonance; the cardiac dulness is dimin- 
ished or lost and percussion gives about the same re- 
sults in that region, as well as over the lower limits of 
the lungs, at the height of either respiratory act; the 
liver dulness and flatness begin lower down than is 
normal, and the liver itself may be pushed below the 
rib margin, as can be proved by palpation and percus- 
sion; resonance may extend unusually low in the 
backs. The hyper-resonant condition of the lung- 
prevents determination of the right border of the 
heart although it extends farther to the right than in 
health. 

On auscultation we are struck by the weakening 
and shortening of inspiration and the prolongation of 



— 44 — 
the low pitched expirations; a change of rhythm for 
the most part, and, in the main, proportional- to the 
impairment of function of the elastic tissue which, in 
health, renders expiration chiefly a passive act. Rales, 
sibilant and sonorous or coarse moist, are usually 
heard; but are traceable rather to the chronic 
bronchitis which almost always accompanies emphy- 
sema than to the latter process itself. The heart 
sounds may be more or less indistinct; the pulmonic 
second is apt to be accentuated by reason of the in- 
creased resistance in the lesser circuit. The tactile 
fremitus and the voice sounds, of course, undergo no 
modification as a rule. In the lesser degrees of 
emphysema the signs are essentially the same in kind, 
though simple enfeeblement of the vesicular murmur 
may be more striking than a change in rhythm. 

There is a rarer form of general emphysema 
called "atrophic," "small-lunged," or "senile" in 
contradistinction to the ordinary " large-lunged," or 
"hypertrophic " form. As the name indicates it is an 
affection of advanced life and involves no enlarge- 
ment of the chest; the lungs, though emphysematous, 
being atrophied and diminished in volume. The 
superficial cardiac space may be increased in size. 
The physical signs are not distinctive. The physical 
signs of permanent local emphysema depend much on 
its extent and the condition to which it is secondary. 
It is apt to occupy the upper lobes and is often 
associated with the more chronic forms of phthisis, 



— 45 — 
the consolidation of which it may mask more or less 
completely. Its detection may demand a thorough 
knowledge of principles on the part of the observer. 

Interstitial or interlobular emphysema has no 
direct physical signs and can scarcely be diagnos- 
ticated during life unless the air escapes from the 
chest through the mediastinum into the subcutaneous 
tissue of the neck and thorax. 

5. Consolidation of the Lung, — This important 
condition is incident to a great variety of diseases, 
and differs so widely in degree, extent, and situation, 
that its detection may be impossible; more or less 
difficult, partly according to the skill of the observer; 
or so easy as to present little or no difficulty to the 
merest tyro in physical examination. An area of con- 
solidation must be of notable size, lie in contact with 
or nearly approach the chest wall, and be pretty com- 
plete, in order to give rise to distinctive signs. Small 
areas, and those larger but deep-seated, of complete 
consolidation, as well as those relatively diffuse but 
imperfect, however near the surface, may be either 
impossible to detect at all, or may have their presence 
betrayed by the rational signs in combination with 
the localization of indistinctive physical signs. Solidi- 
fication of the lung, as the term implies, involves a 
diminution in the amount of air proper to the part, 
which diminution is generally combined with, if not 
dependent on, an increase of the solids; it is, there- 
fore, the opposite of emphysema, though the two con- 



- 46 — 

ditions may be associated as has already been seen. 
There are two chief ways in which solidification may 
be brought about, from without or from within; the 
first is compression, and is incident especially to large 
pleural accumulation; the second is due to oblitera- 
tion of the air cells by interstitial or other growth; to 
filling of the cells with morbid products, as in pneu- 
monia lobar or lobular, infarction of the lung, gener- 
ally to a less degree in pulmonary oedema; to collapse 
of the lung, as in atelectasis due to capillary bron- 
chitis; or to a combination of these processes. By 
any or all of these means the amount of air in the 
part is diminished, and its access to the vesicles is im- 
peded or prevented, while the atmospheric circulation 
in the upper air passages and larger bronchi remains 
essentially unchanged. The condensed lung tissue, 
moreover, conducts sounds produced in the larger 
bronchi, trachea, and at the rima glottidis compara- 
tively unchanged to the periphery, these sounds being 
in health modified and broken up in the ramifications 
of the bronchioles, and in the air cells themselves. 
Consequently, many of the physicial signs of consoli- 
dation are the same in kind as those found in health 
over the upper and larger air passages. 

The physical signs, then, of complete consolida- 
tion of considerable extent are as follows: 

Inspection may or may not show notable dyspnoea 
and -cyanosis, according to the proportion of lung in- 
volved in the solidification and the rapidity with 



— 47 — 
which this has come on; there may, also, be a dis- 
parity in the respiratory movements of the two sides 
if the change is unilateral, though this sign is never as 
marked as in pleural accumulation. The tactile fre- 
mitus is increased over the solidified area, which is 
very dull or flat on percussion with increased resist- 
ance under the finger. But the tympanitic resonance 
of the stomach may be conducted over the left chest 
if the left lung or its lower portion is solidified. 

The respiratory murmur is bronchial over the 
affected area, and usually intense, and bronchophony 
and whispering bronchophony are marked. Rales 
are generally, though not necessarily, present, their 
abundance and character depending largely on the 
cause of the consolidation. In the second stage of 
lobar pneumonia they may be entirely absent, or 
coarse rales due to secretion in the larger bronchi 
may be heard. Medium and fine moist rales are 
common, at least over portions of the solid area; and, 
in general, the rales over solid lung are apt to be loud 
and somewhat ringing — the consonating rales of Skoda, 
They may be heard only after cough, or at the end of 
deep inspiration. Complete and extensive consolida- 
tion is more often associated with lobar pneumonia 
than with any other one disease, perhaps than with 
all others put together. 

Vesicular resonance and respiration over the 
sound lung may be exaggerated. 

The condition is also incident to large pleural 



_ 4 8 — 

accumulation, some cases of phthisis and gangrene, 
and to some new growths. 

Partial consolidation may give rise to dyspnoea 
and cyanosis; percussion is dull, and may also be 
tympanitic, as in the first and third stages of fibrinous 
pneumonia, and over the relaxed and somewhat con- 
densed lung in pleural effusion. Auscultation gives 
a broncho-vesicular respiration, often of slight inten- 
sity, in which one or the other quality predominates 
according to the degree and extent of the solidifica- 
tion. The heart sounds are heard with remarkable 
distinctness over a solidified lung in or about the cardiac 
area. The tactile fremitus, and vocal fremitus and 
resonance, are increased. Rales are practically al- 
ways present, usually of the medium and fine moist 
varieties, sometimes so abundant as to mask the re- 
spiratory murmur; in the first and third stages of 
lobar pneumonia the fine dry, or crepitant, rale may 
be heard. Coarse rales, moist or dry, are accidental, 
and depend on the presence of secretion or inflamma- 
tion in the larger bronchi. In lobar pneumonia an 
opportunity may be afforded the observer of studying 
the whole process of extensive consolidation from 
start to finish, though cases are usually not seen until 
solidification is marked. The waning gives rise to 
the same signs as the waxing process, except that 
their development is generally slower in the former, 
and that the order of their appearance is reversed. 

Partial consolidation is, or may be, met with in 



— 49 — 
the first and third stages of pneumonia, in broncho- 
pneumonia and atelectasis, phthisis, moderate pleural 
accumulation, infarction — hemorrhagic and embolic 
— oedema and hypostatic congestion, pulmonary haem- 
orrhage, gangrene and infiltrating neoplasms. These 
processes are to be differentiated by a careful con- 
sideration of the localization, mode of onset, course, 
and progress of the disease, character of the sputum, 
presence or absence of disease in other organs or 
parts — in short, by putting together and weighing all 
the information which can be gained by questioning 
the patient or his friends, as well as by an examina- 
tion of all his organs, and his body as a whole. 
Even then it is sometimes necessary to hold one's 
opinion in reserve. Consolidation, complete or par- 
tial, may be variously combined, as with effusion, 
emphysema, bronchial obstruction, or cavity. 

The more important physical signs of each of the 
above affections are as follows: 

i. Phthisis, (a) First stage. — If consolidation 
is very slight the sole physical sign may be the pres- 
ence, especially at one apex, of a dry crumpling or 
creaking sound, or of subcrepitant rales, more or less 
abundant, and heard sometimes only after cough or 
during the quick inspiration which should follow that 
act. If consolidation is more advanced there is dul- 
ness on percussion, broncho-vesicular respiration, in- 
creased fremitus, and a degree of bronchophony, in 
addition to fine and medium rales. 

4 PP 



— So — 

The commencing process is usually, though not 
necessarily, unilateral; and involves the apex by prefer- 
ence. Hence any signs in that region should be re- 
garded with suspicion. A sputum examination may 
settle the diagnosis before any physical signs can be 
obtained. 

(b) Second stage. Here the signs are the same 
except that the consolidation is usually more marked 
and extensive while the breaking down lung tissue 
gives rise to more abundant and more varied rales. 

(c) The criterion of the third stage is generally 
considered to be cavity formation, the distinctive 
signs of which will be set forth later. A cavity may 
form in the midst of a single and very circumscribed 
area of disease; and, on the other hand, no cavity 
which can be detected by physical signs may be 
formed in cases of wide spread disease. As a rule, 
however, cavities are associated with a more or less 
extensive and chronic process. It is, of course, un- 
derstood that such a classification as the above is arti- 
ficial rather than natural. 

Fibroid phthisis, so-called, is a very chronic pro- 
cess the main pathological characteristic of which is 
the substitution of connective tissue for vesicular struct- 
ure. It is generally unilateral, may begin at the base 
as a result apparently of pneumonia or pleurisy, often 
contracts and distorts the chest, and gives rise to well 
marked signs of consolidation. It may draw the heart 
out of place toward itself and leave an undue portion 



— si — 

of the organ uncovered by lung. At the same time 
the heightened resistance in the pulmonary circulation 
induces dilatation and hypertrophy of the right ven- 
tricle, the fingers and toes are often clubbed, and the 
usual phenomena of failure of the right heart may 
supervene. The strongest diagnostic feature lies in 
the association of such physical signs as the forego- 
ing, and of great dyspnoea on exertion, with a surpris- 
ingly good condition of general nutrition and an 
afebrile state. 

2. Lobar Pneumonia is ordinarily an acute 
febrile process but may in the aged be latent as far 
as symptoms are concerned. 

(a) The first stage, that of engorgement, so- 
called, gives at first slight dulness and feeble respira- 
tion with, in typical cases, the crepitant rale; the 
favorite localization of these signs being over a lower 
lobe. Pleural friction, especially in the absence of 
the crepitant rale, may obscure diagnosis at this time. 

(d) As the first passes into the second stage, 
dullness increases in intensity and area; respiration 
becomes broncho- vesicular, and then bronchial; the 
tactile fremitus is increased, and bronchophony ap- 
pears. Crepitant and subcrepitant rales maybe heard 
over incomplete areas of solidification; over complete 
areas no rales are heard except those attributable to 
secretion in the larger bronchi. 

(c) In the third stage, as the exudation is ab- 
sorbed and air begins to re-enter the alveoli, the lung 



— 52 — 

finally quite recovering its normal condition, the same 
signs return, but in an inverse order. 

3. Broncho-pneumonia is an acute febrile process^ 
secondary to bronchitis, bilateral, and incident especi- 
ally to the extremes of life. One form is the so-called 
" inhalation pneumonia," excited particularly during 
the course of severe adynamic fevers by the inhalation 
of particles of food, or of secretion from the mouth 
and upper air passages. The diagnosis rests on the- 
association of such circumstances as the above, with 
more or less diffused bilateral fine moist rales, and 
the evidences of scattered areas of solidification of 
varying size. 

4. Atelectasis gives rise to signs which, in them- 
selves, may be identical with those of broncho-pneu- 
monia, and which never present any sharp distinction 
therefrom except that in atelectasis the areas of con- 
solidation may change their seat from day to day. It 
is a condition rather than a disease, and the chief 
clinical peculiarity is that it is not febrile. It is often; 
combined with lobular pneumonia, and is then incap- 
able of diagnosis. 

5. Hypostatic Pneumonia, or Congestion, affects 
the dependent portions of the lungs of those whose 
hearts are weak, whose breathing is superficial, and 
who lie much in one position — postulates which are 
most frequently met in the severe infectious diseases^ 
It is bilateral and, naturally, most common in the 
posterior bases. 



— 53 — 

Its signs are: Dullness on percussion; feeble res- 
piration, sometimes partly bronchial in quality; and 
■coarse and fine moist rales. 

6. (Edema of the Lung may be associated with, 
-and constitute an important part of, hypostatic con- 
gestion. But transudation of pure serum into the 
lung tissue and alveoli may occur in obstructive dis- 
ease or failure of the heart from any cause, as well 
as in Bright's disease/ The physical condition and 
localization are much the same as those of hypostatic 
pneumonia, though the process seldom reaches so 
high a degree, and the diagnosis must therefore de- 
pend largely on the associated conditions. 

A rare form of acute primary and general pulmo- 
nary oedema is described, which is characterized by 
relatively sudden and intense dyspnoea, the universal 
presence of subcrepitant mixed with coarser moist 
rales all over both sides of the chest, and a very copi- 
ous serous expectoration, generally pink or pinkish 
from admixture with blood. 

6. Gangrene of the Lung has no distinctive 
physical signs, and the diagnosis rests entirely on the 
liorrible foetor of the breath and sputum, in combina- 
tion with signs of limited or diffuse consolidation. It 
is to be differentiated only from putrid bronchitis, and 
a bronchiectatic cavity with decomposing contents. 
Lung consolidation and elastic fibres in the sputum 
-distinguish it from the pure cases of the former; with 
the latter it may be combined, and in this case the 
nistory of the patient can alone remove doubt. 



— 54 — 

8. In Hczmoptysis, some of the blood may be re- 
tained and give rise to the signs of partial consolida- 
tion, or to those of a more or less extensive capillary 
bronchitis. The history of the case, or the actual 
observation of the haemorrhage, are requisite for 
diagnosis. 

9. Hemorrhagic and Embolic Infarctio?i may be 
followed by bloody expectoration and give rise to 
solidification large or complete enough to produce the 
physical signs of that condition. The former can be 
diagnosticated only by excluding every other cause 
for the above combination of rational and physical 
signs — a task of the greatest difficulty unless there is 
a history of trauma. The latter requires a source for 
the embolus either in the right heart (especially 
thrombosis in the auricular appendage) or in the 
peripheral venous circulation. Pleurisy may be ex- 
cited at the base of the wedge-shaped mass. Given a 
clear source of the embolus, sudden dyspnoea and 
pleuritic pain may awaken strong suspicion, which 
haemoptysis and the signs of consolidation convert 
into certainty; but the process may not reach the sur- 
face and cause pleurisy, nor does haemoptysis always 
occur. Diagnosis may therefore be impossible. 

6. Pulmonary Cavities. — These must be of a cer- 
tain size to give rise to distinctive signs, and it stands 
to reason that a cavity in the deeper portions of the 
lung surrounded by more or less healthy tissue will 
be less easily detected than a smaller one near or at 



— 55 — 
the outer surface. Even distinctive signs are materi- 
ally influenced by the presence or absence of free 
communication with the bronchial tract, the amount 
of secretion or other fluid in the cavity, the smooth- 
ness and tension of its walls, and the amount of con- 
solidated lung surrounding them. 

Distinctive signs are cracked-pot or amphoric 
percussion note; bronchial, cavernous, or amphoric, 
respiration; coarse gurgling, or amphoric rales; bron- 
chial, cavernous, or amphoric, voice sounds and whis- 
per; and greatly increased fremitus, which may be 
even painful to the ear. 

Cavities are incident especially to phthisis, in 
which case their favorite seat is the upper lobes; or to 
bronchiectasis, gangrene, and abscess of the lung; in 
the three latter the lower lobe is more frequently the 
seat. Which cause is operative in a gfven case must 
be ascertained by sputum examination, the history 
and course of the disease, and the associated signs, 
rational and physical. 

7. Thoracic Tumors ', Non-Aneurismal. — These 
are all solid, but have little else in common. Of 
course the physical signs must vary with the starting 
point of the growth, its size, whether it infiltrates or 
compresses the lung, is single or multiple, compresses 
a large bronchial, arterial, or venous trunk, the oeso- 
phagus, or an important nerve. The indirect or 
pressure effects will be better discussed under the 
head of aneurism which far surpasses in frequency 



- 56- 

other thoracic tumors. The pathological nature of 
the tumor has less influence on the physical signs than 
its origin and size. There are, indeed, no distinctive 
signs of tumors in this situation; they may simulate 
.solidification of the lung, deep or superficial, or pleural 
effusion. Ecchinococcus cysts, projecting from the 
upper surface of the liver into the space normally occu- 
pied by lung, are especially liable to give rise to the last 
named error, an error which tapping may fortify un- 
less the fluid is examined chemically or microscopic- 
ally. Enlargement of the bronchial glands, cancer, 
and sarcoma, are the other least rare forms of intra- 
thoracic new growths. The writer has seen a case of 
myxo-chondroma. In general the diagnosis must be 
reached by exclusion. Growths which start from or 
approach the pleura are apt to excite inflammation of 
that membrane with fibrinous, serous, or hemor- 
rhagic, product. 



PART IT -HE ART AND AORTA. 
CHAPTER I. 

THE HEART IN HEALTH. 

Experience as a teacher has led the author to 
believe that the chief difficulties encountered by 
students in the physical diagnosis of cardiac disease 
depend on the lack of a sufficiently intimate and 
accurate knowledge of the anatomy and physiology 
of the heart. Therefore the structure of the organ 
itself as well as its relation to surrounding organs 
and parts, and the mechanism of the circulation, 
should be first thoroughly mastered. Speaking 
broadly, the diagnosis of valvular disease of the heart, 
to say the least, is less difficult than is that of pul- 
monary disorders. Yet students seem to find it more 
so, as I believe for the reason stated above; their 
knowledge may be fairly accurate, but is usually not 
quickly enough at command. We must, however, 
here presuppose the possession of most of this know- 
ledge, and shall dwell upon it only, as it were, inciden- 
tally in describing the methods employed in cardiac 
examination. It is hoped that the little plates may 
be of service. 

i. Inspection may, in chests well covered by fat 
or muscle, show little or nothing, especially if the 



- 5« - 
heart is acting quietly; in women the mamma is very 
apt to mask the impulse. In thin persons, or in the 
stouter if the heart is excited by exercise or emotion, 
the movement communicated to the chest-wall by the 
ventricular contraction is generally seen in the fifth, 
occasionally in the fourth, left interspace and inside 
the mammillary line. This is called the apex beat. 
In children it lies rather farther to the left than in 
adults, and often occupies the fourth space. It is apt 
to be less distinct, or absent, with a dorsal decubitus; 
moves somewhat to the right, often as far to the left 
as the anterior axillary line, with the right and left 
lateral decubitus respectively. In very thin persons, 
especially if there be retraction or solidification of 
the corresponding portion of lung, a basic movement 
may be seen. 

2. Palpation in health is chiefly of value in local- 
izing the apex beat in case this cannot be done by the 
eye, or as confirmatory of the results of inspection. 
The shock of the systole can sometimes be felt when 
it cannot be seen. But palpation may also give nega- 
tive results, and under much the same circumstances 
as inspection. A change of position on the part of 
the patient may yield results quite analogous to those 
above alluded to under inspection. A basic pulsation 
may also be felt in some persons. 

3. Percussion enables us in most cases to map 
out the heart's area with great accuracy provided that 
the method is skillfully practiced. Gentle percussion 



— 59 — 
is flat over the small and somewhat triangular space 
where the pericardium is uncovered by lung and lies 
in immediate contact with the chest wall. This space 
corresponds to the body of the right ventricle, the 
lingula of the left lung covering with a thin layer the 
very apex, which is formed, as is well known, by the 
left ventricle. The lower boundary of this space can- 
not be determined by percussion as the heart and 
liver, both solid and non-resonant bodies, here come 
together separated only by the diaphragm. The right 
border of the space is the left edge of the sternum; its 
upper edge near the sternum is the fourth costal car- 
tilage, and the left border runs thence outward and 
downward toward the apex. This is called the super- 
ficial cardiac space. It varies appreciably in size with 
forced inspiration or expiration. The deep cardiac 
space comprises the greater portion of the heart, which 
is covered by a layer of lung and by the sternum, and 
therefore extends chiefly to the right and upward, 
though also somewhat to the left, of the superficial 
space. The deep space corresponds to a portion of 
the right ventricle, a strip of the left, and to the 
auricles. Percussion over it is dull, more or less. 
The accuracy with which it can be mapped out by 
percussion varies in different persons. In some the. 
extreme right border can be made out by careful per- 
cussion about three centimeters to the right of the 
right sternal border; in others it cannot. The thick- 
ish layer of the lung and the resonance of the sternum 



— 6o — 

are disturbing factors. But the negative evidence of 
a failure to detect dulness to the right of the sternum 
between the third and fifth cartilages is important in 
determining the absence of enlargement of the right 
cavities, dislocation of the heart, or notable peri- 
cardial effusion. Above, the dulness begins at the 
third rib; the left border follows a line which passes 
slowly downward to the fourth rib, and then rapidly 
downward to the extreme apex. The lines are but 
little modified by a change from the recumbent to the 
vertical position or vice versa; but the lateral borders 
move somewhat to the right or left in one or the 
other lateral decubitus. 

4. Auscultation enables us to listen to the sounds 
produced by the heart in action and to determine 
their nature. These sounds are two in number and 
are distinguished as the first and second. The first 
corresponds in time to the ventricular systole and has 
a double origin; the change of tension which the 
auriculo-ventricular valves undergo when they close 
the mitral and tricuspid orifices, and the muscle sound 
caused by the contraction of the ventricles. That the 
impingement of the heart against the chest wall 
enters into the production of the first sound is open 
to more question. This sound is low in pitch, long 
in duration, and may be described as booming in 
quality. It is heard all over, and often even far be- 
yond the limits of the heart, but is loudest at the 
apex. Here that portion of the sound which is attri- 



— 6i — 

butable to the mitral valve is most marked, while to 
estimate the tricuspid element we listen over the 
middle of the lower part of the sternum. In health 
this differentiation is not much practiced but it may 
become important in some diseased conditions. The 
second sound follows almost immediately on the first, 
and is attributable to vibrations set up in the aortic 
and pulmonic valves by the change of tension to 
which they are subjected at their time of closure. As 
compared with the first sound it may be characterized 
as sharp, short, and valvular. It also is heard all 
over and beyond the heart's area, but is loudest at 
the base of the organ. To determine the relative 
value of the two elements composing it we listen over 
the second right interspace at the sternal border for 
the aortic portion, a point somewhat above and to the 
right of the seat of the valves themselves, but that at 
which the aorta nearest approaches the external sur- 
face. The sound is in health somewhat louder and 
sharper here than it is over the corresponding point 
on the left side where we are accustomed to study that 
portion of the second sound due to the pulmonic 
valves. If there is any difficulty in distinguishing 
the sounds from one another the finger may be placed 
on the apex, or, if this cannot be felt, on the caro- 
tid; the sound which is synchronous with the apex 
beat or the dilatation of the artery is, of course, the 
first. The second sound, marking the closure of 
the semilunar valves, is followed by the long pause of 



— 62 — 

the heart, as it is sailed, during which the blood is 
passing under gentle pressure and in a noiseless stream 
from the auricles to the ventricles — the ventricular 
diastole. Toward the end of the ventricular diastole 
the auricles contract to empty themselves and com- 
plete the filling of the ventricles, and this is promptly- 
followed by the ventricular systole and the com- 
mencement of another cardiac revolution. In health 
the auricular systole gives rise to no sound which we 
can hear, and one revolution succeeds another, equal 
in force and regular in rhythm. The rate is slower or 
faster from individual peculiarity, rest or exercise, and 
the absence or presence of emotional excitement. 
The distance to which the sounds are propagated de- 
pends in a measure on the tension of the chest wall; 
the greater the tension the more distant the propaga- 
tion. 

To sum up, the first sound marks the ventricular 
systole, the second the beginning ventricular diastole 
which continues up to the next ventricular systole 
but, just before its close, is synchronous with the 
auricular systole. 

It should always be remembered that changes in 
the lungs may cause an apparent modification in many 
of the physical signs of the healthy heart. Thus, air 
or liquid in the pleural cavity frequently produces 
striking changes in the position of the central organ 
of the circulation, which, fixed at the base by the 
great vessels, can on them be swung from side to side 



- 63 - 

and also rotated in a measure; it can be pushed out of 
place by mediastinal or other tumors, or by the healthy 
lung when its fellow is markedly retracted; it can 
descend with the diaphragm when that muscle is de- 
pressed by large lunged emphysema, the dilated lung 
at the same time effacing the superficial cardiac space, 
though emphysema of this degree is nearly sure to 
cause secondary dilatation and hypertrophy of the 
right cavities; the seat of maximum intensity of its 
sounds may be changed by solidified lung; or adven- 
titious sounds arising in the lung or pleura may sim- 
ulate those of endo- or pericardial origin. Again any 
abdominal disease or process which unduly forces up 
the diaphragm is also liable to alter the normal rela- 
tions of the healthy heart. Transposition of the 
viscera must also be mentioned. In every examina- 
tion these sources of error must be thought of and 
allowed due weight. Of course cardiac is often co- 
existent with pulmonary or abdominal disease, and a 
state of affairs may thus be produced the unravelling 
of which demands the greatest acumen and the most 
accurate knowledge. 



CHAPTER II. 

THE HEART IN DISEASE. 

Just as in pulmonary, so in cardiac examination 
physical signs lead directly to physical condition, in- 
directly to disease. But the number of diseases which 
in the heart have a similar underlying physical con- 
dition is much smaller than obtains with the organs 
of respiration. It consequently seems wiser to pursue 
a somewhat different order in dealing with the heart 
from that which was followed with the lungs. 

Enlargement of the Heart. — Enlargement 
may be either general or local, involving the whole 
organ or only one or more of its component divisions. 
It may, moreover, be due either to dilatation or to 
hypertrophy; or, as is usually the case, to a com- 
bination of the two. The physical signs of these 
several conditions vary so that they must be classified 
and discussed separately as far as truth to nature will 
permit. 

i. Simple hypertrophy means an increase in the 
bulk, and possibly in the number, of the muscular 
fibres without an increase in the size of the cavities 
which they enclose; a condition which, in its pure, and 
especially in its general, form, is rare. 

The physical signs to which it gives rise are: an 
apex beat unusually evident to the eye, situated lower 
and farther to the left, and slightly more diffuse than 



- 65 - 

is normal, and communicating a strong shock to the 
finger applied to the apex region; a slight general in- 
crease in the area of cardiac dullness; and unusually 
loud and distinct sounds which preserve alike their 
relative, and seat of maximum, intensity. It may be 
stated here that hypertrophy is a less important factor 
in producing an increase in the size of the heart than 
is dilatation. It consequently cannot be expected by 
itself, to markedly increase the area of percussion 
dullness. General simple hypertrophy is apt to be 
associated with general plethora. 

It is in the left ventricle that local simple hyper- 
trophy is most common, and in this case the apex 
beat is lowered, marked alike to the hand and eye; 
there is little if any increase in percussion dullness, 
but that little is to the left; and the first sound in the 
mitral area is loud and prolonged while the aortic 
second, as heard in the second right interspace, is 
more or less sharply accentuated. The pulse is strong, 
slow, regular, usually incompressible and full between 
the beats — of high tension. Pure, or concentric, 
hypertrophy of the left ventricle is met with especially 
in cases of chronic, and, above all, of interstitial 
nephritis, and is to be regarded as the result of and 
means of compensation for the heightened pressure in 
the peripheral arterial circulation so characteristic of 
that disease. In those very rare cases of pure aortic 
stenosis it is through simple hypertrophy of the left 
ventricle that compensation may be secured. 

5 pp 



— 66 — 

This condition of the right ventricle is very rare. 
The signs are: An apex beat moved to the left rather 
than lowered, and diffused toward the epigastrium; a 
slight increase in the transverse dullness to the right 
of the sternum; and an unusually loud first sound in 
the tricuspid area with accentuation of the pulmonic 
second, as heard at the second left interspace near 
the sternal border. The condition is incident to and 
compensatory for increased pressure in the lesser, or 
pulmonic, circuit, as in emphysema. 

Simple hypertrophy of the auricles can scarcely 
be said to exist. Their walls are so thin and feeble 
as compared to those of the ventricles that heightened 
pressure is sure to result in dilatation, with which 
hypertrophy may or may not be combined. 

2. Simple Dilatation denotes a condition in which 
one or more of the cavities is increased in size with- 
out thickening of the wall. In its pure form it is an 
even rarer condition than simple hypertrophy. 
General dilatation is manifested by absence or great 
feebleness of the apex beat and radial pulse, for the 
former of which a thick chest wall will not account; 
general increase in the cardiac dullness; and feeble- 
ness of the sounds, the first being shorter and higher 
pitched than in health and approximating in character 
to the second. Outside of the heart there are usually 
the evidences of venous stasis, such as dropsy, in- 
ternal, external, or both. The condition is to be dif- 
ferentiated from pericardial effusion, and in a manner 



_ 6 7 - 

which will be discussed later. The usual cause is de- 
fective blood formation and consequent failure of 
tissue nutrition, under which the heart wall yields to 
internal pressure. It would occur oftener than it 
does were it not that in these very cases the internal 
pressure is generally far lower than in health and the 
patients are incapable of increasing it by exercise. 

Local dilatation is more apt to befall the auricles 
than the ventricles, and the right ventricle more than 
the left. The only positive signs of auricular dilata- 
tion are increased dullness and perhaps pulsation at 
the base of the heart; in the second left interspace if 
the left auricle be affected, in the third right inter- 
space if the right auricle; corroborative evidence is 
afforded by finding in another chamber of the organ 
a cause to which the auricular dilatation can be at- 
tributed, and secondary it practically always is. 

Dilatation of the right ventricle brings that 
chamber still more to the front than in health and, 
through rotation of the organ, the left ventricle may 
cease to form the apex. The visible pulsation, if any 
is visible, thus becomes diffuse, short, weak, and 
rapid, perhaps irregular; entirely different from the 
slow, heaving, powerful, and usually regular impulse 
of simple hypertrophy; the area of cardiac dullness, 
especially transversely and to the right of the sternum, 
is increased; the first sound is short and high pitched 
— valvular, — resembling greatly the second and dis- 
tinguishable from it with difficulty. There may be a 



— 68 — 

marked discrepancy between the beats over the heart 
and in the radial artery, many of the imperfect con- 
tractions failing to reach the periphery. Tricuspid 
incompetency is apt to result from the dilatation alone, 
and may be betrayed by a systolic murmur, loudest 
over the seat of the tricuspid valves, the lower mid- 
sternal region; dilatation of the right auricle may be 
determinable by percussion. Evidences of venous' 
stasis in and behind the lungs are usually not want- 
ing. The causes are, in a word, increased resistance 
in the pulmonary circuit and a failure to establish 
compensatory hypertrophy. 

The signs of simple dilatation of the left ventricle 
differ from those above described, in that the area of 
dullness is increased downwards and to the left; the 
impulse, if visible or palpable, is less diffuse and far- 
ther to the left; and the murmur, if heard, belongs to 
the mitral area, while percussion may show enlarge- 
ment of the left auricle. The cause is undue resist- 
ance in the systemic circulation, or at the aortic 
orifice, and a failure to establish compensatory 
hypertrophy. 

The above more or less special and somewhat 
theoretic considerations must be supplemented by 
some of a more general character. 

As has been already stated, hypertrophy and 
dilatation are generally combined and dependent on 
a common cause, namely, increased resistance beyond 
the seat of the enlargement. Augmented internal 



- 69 - 

pressure tends at first to stretch the walls of the 
cavity, and the integrity of the circulation can then 
only be maintained by a proportional increase in the 
force of the muscular contraction of the chamber, or 
chambers, behind the cause augmenting the pressure. 
If this cause be in operation but a short time the re- 
sulting dilatation may subside without the superven- 
tion of hypertrophy, the demand for heart power 
being lessened by rest, and, perhaps, artificial means 
— acute dilatation. But if the cause be longer opera- 
tive, the heightened demand can be met only by an 
increase in the muscular bulk — hypertrophy. If this 
is sufficient to dominate the dilatation, and thus re- 
establish the balance of the circulation, we speak of 
the lesion as " compensated." But compensation can- 
not take place unless there be a reserve nutritive 
power in the organism in general, and in the heart 
wall in particular; and it is obvious enough that all 
degrees of compensation are encountered in different 
cases, or even in successive stages of the same case. 
Whether hypertrophy or dilatation is predominant, 
depends on several factors, such as the rapidity with 
which the cause has come into operation, its perman- 
ency, its degree, the part on which it operates, its 
time of operation, the general and local reparative 
power of the individual, and the judiciousness of the 
treatment which he receives, or allows himself to re- 
ceive. Other things being equal, a cause of insidious 
onset and very gradual increase, such as the high ten- 



— 70 — 

sion of chronic Bright's disease is apt to be, offers a 
better chance for compensatory hypertrophy; acute 
dilatation may subside without requiring much, if any,, 
hypertrophy; great resistance demands more than 
slight; the ventricles, particularly the left, are capable 
of an increase in muscular power which is quite im- 
possible for the thin-walled auricles to attain in even 
proportional measure; a hollow muscle will yield more 
readily to a strain applied while it is weakest than 
while it is strongest — during dilatation than during 
contraction; a muscle cannot increase in size and 
power unless the blood is good and can gain free ac- 
cess to it, unless the nervous centres which influence 
its nutrition are in fair condition and uninterrupted 
connection with it, and unless the muscular tissue 
itself is so far free from fatty, interstitial, or other 
pathological change as to be still capable of sufficient 
reparative growth. 

It will thus be seen that, speaking broadly, hyper- 
trophy is a conservative, dilatation a destructive, pro- 
cess. At the same time, in many a condition, a cer- 
tain amount of dilatation is salutary, nay essential. 
The all-important thing is that hypertrophy be pre- 
dominant. 

The diagnosis of hypertrophy is easier than that 
of dilatation, in that there are fewer sources of error 
in determining the presence of enlargement with an 
increase in power than obtain in enlargement with 
diminished power. The powerful, heaving, and dis- 



— 7i — 
placed apex beat, and strong, slow, regular pulse are 
striking and distinctive enough; but changes in the 
lungs and in the pericardium may closely simulate 
the dilated heart. The writer has been asked to tap 
the pericardium in a case in which, after careful ex- 
amination, he believed the signs to depend on dilata- 
tion. 

B. DISEASES OF THE MUSCULAR STRUCTURE OF THE 

HEART NOT NECESSARILY ASSOCIATED WITH 

APPRECIABLE ENLARGEMENT OF 

THE ORGAN. 

These processes offer some of the most difficult 
diagnostic problems which we are called upon to 
solve, and are oftentimes impossible of accurate 
solution with the means which we now have at com- 
mand. They are: Myocarditis, acute and chronic; 
fatty infiltration and degeneration; aneurism of the 
heart; and new growths. All are liable to produce 
weakened heart action, and may, but by no means in- 
evitably, cause modifications in the size of the heart. 

Acute Myocarditis may be febrile, occurring, as it 
does, chiefly in the course of acute rheumatism or 
other infectious diseases. It may be associated w r ith 
endo- and peri-carditis and can be diagnosticated 
only by relatively sudden cardiac weakness occurring 
under conditions known to predispose to acute in- 
flammation of the heart muscle and as a cause for 
which endocarditis and pericarditis can be either con- 
fidently excluded or determined to be insufficient. 



— 72 — 

Chronic Myocarditis, or Fibroid Degeneration, may 
also produce the local and general signs of cardiac 
weakness; but is chronic and persistent, not acute. 
The diagnosis is alike surrounded with difficulties, 
and can only be made when other causes of chronic 
weakness, such as valvular disease and fatty degenera- 
tion can be excluded or fairly judged to be insufficient 
for the production of the signs and symptoms. It is 
well known that the connective tissue growth in ad- 
herent pericardium frequently invades the heart wall; 
if the latter condition can, therefore, be made out the 
existence of chronic myocarditis can be pretty con- 
fidently affirmed. 

Aneurism of the Heart is due to a local giving way 
of a portion of the heart wall weakened or thinned by 
disease and consequently unable to withstand a pres- 
sure which the rest of the muscle can still support. It 
may arise acutely as the result of acute local myo- 
carditis, ulcerative endocarditis, or more or less sud- 
den impairment of blood supply; the chronic form is 
generally the result of chronic myocarditis. In either 
case rupture of the heart wall and speedy death may 
ensue. The cases are rare at the best, and there are 
no distinctive signs whatever on which the diagnosis 
can be based. It is, therefore, unnecessary to say 
more about them here. 

New Growths of the Heart can be dismissed as 
quickly, having, if possible, even less clinical interest 
than aneurisms. The occurrence of pericarditis in a 



— 73 — 
cancerous patient for which no other reasonable ex- 
planation can be given might warrant a shrewd guess 
as to the presence of a secondary deposit in the sub- 
stance of the heart. 

Fatty Infiltration of the Heart, Fatty Overgrowth or 
Obesity of the Heart, is, in typical cases, to be sharply 
distinguished from fatty degeneration both clinically 
and pathologically. The muscular fibres are intact 
unless atrophy is brought about by the pressure of 
the fat layer between the bundles. This permeation 
of the wall with fatty tissue, which also envelopes it 
in a thicker or thinner layer, heightens the embarrass- 
ment of the circulation caused by the abundant sub- 
cutaneous, omental, and other fatty deposits. The 
physical signs are, for the most part, negative or in- 
distinctive, the enlargement of the heart being often 
masked by the subcutaneous fat which may render 
percussion valueless. The diagnosis must conse- 
quently rest mainly on the general and local signs and 
symptoms of cardiac weakness or insufficiency in an 
obese person who usually is addicted to the excessive 
comsumption of malt liquors and leads a sedentary 
life. The cardiac insufficiency may be so great as to 
cause general dropsy. Cases are encountered in which 
fatty infiltration is combined with the graver condition 
next to be described. 

Fatty Degeneratio7i of the Heart is a term de- 
scriptive enough of the condition to which it is ap- 
plied, and it is obvious that the contractile power of 



— 74 — 

the affected muscle must be impaired proportionally 
to the extent and degree of the change. Here, again, 
diagnosis must be largely indirect, if it can be made 
at all. We must have the signs of a chronically weak 
heart and exclude all other causes of that condi- 
tion, such as dilatation, chronic myocarditis, ad- 
herent pericardium, and the like. Late middle or 
advanced life, atheroma, arcus senilis, and alcoholic 
excess are factors to be taken into account in mak- 
ing the diagnosis. A failure of suitable treatment 
by rest and cardiac tonics is considered by some a 
diagnostic point; this simply shows, however, that the 
lesion, whatever its nature, is beyond repair. Slow- 
ness of the pulse is not considered of as much diag- 
nostic value as it was formerly. In grave anaemia, 
knowledge derived from autopsies enables us to diag- 
nosticate fatty degeneration with certainty. All sorts 
of combinations of fatty degeneration with other 
pathological changes are encountered. 

It will be readily seen that the positive diagnosis 
of the conditions comprised in the above division is 
nearly always very difficult and often impossible. 
Murmurs, especially in the mitral area, are often 
heard in them and may depend either on co-existent 
valvular disease or simply on dilatation and such in- 
efficiency of the muscular contractions that relatively 
or absolutely healthy valve-curtains fail to close an 
auriculo-ventricular orifice during the ventricular sys- 
tole. These latter murmurs will receive further con- 



— 75 — 
sideration under the head of functional disorders of 
the heart. So much has been said about cardiac 
weakness that it is, perhaps, well to sum up the signs 
of its presence. These are, in brief, an apex beat 
more or less evident to the eye, and more or less 
difused toward the right or displaced to the left, 
according to the amount of dilatation and the part of 
the heart most affected; or the apex beat may be 
entirely absent; the impulse to the finger is short and 
feeble, usually rapid, often irregular; the first sound 
is weak, short, and high pitched, and may be accom- 
panied or replaced by a murmur; the second sound is 
generally also feeble, but may be accentuated in 
either the aortic or pulmonic area if the weakness is 
predominant in one or the other side of the heart 
rather than general. Basic murmurs, unless of haemic 
origin, are less common than those in the mitral area. 
The pulse is feeble and some of the heart beats may 
fail to reach the wrist; the patient is incapable of 
much exertion, physical or mental; syncopal attacks 
are common; there may be cyanosis and other evi- 
dences of venous stasis. 

We must be ever on our guard not to mistake a 
mere temporary or accidental weakness due to 
emotional or other causes for one that is real, chronic, 
or more or less permanent. One should hesitate, 
therefore, to make a positive diagnosis of one of the 
above described conditions, all of which are serious, 
while some are of the utmost gravity, after a single 
examination however thorough it may be. 



- 7 6 - 

C. VALVULAR DISEASE OF THE HEART. 

The two main causes of valvular disease are 
endocarditis, largely of rheumatic origin, and athe- 
roma. The first is chiefly operative in early life 
and affects the mitral valve by preference, though 
the others, and especially the aortic, are far from 
enjoying immunity; the latter is a senile change to 
which strain, syphilis, and alcohol predispose; and 
is more apt to extend to the aortic valves from 
the aorta itself than to originate in the former 
situation. The actual valvular damage is, in a 
sense, of less importance than the results which it 
entails to the heart-wall and to the organism as a 
whole, results largely of a mechanical nature. The 
immediate effects of damage to a valve are one of two, 
which may be found either singly or both in combina- 
tion. That is to say, an impediment may be placed in 
the way of the onward passage of blood through a 
valve; or, from failure to close an orifice completely, 
leakage and a backward current are established. The 
former condition is called stenosis or obstruction; the 
latter regurgitation, incompetency, or insufficiency. 
Just as only one, or both of these conditions simul- 
taneously, may be present at any orifice, so they may 
be confined to one orifice, or involve two or more at 
the same time. Whatever the nature or seat of the 
lesion, its broad results are the same, the differences 
bein mainly in details. Whether a valve is stenosed 
or incompetent, the tendency is necessarily toward an 



— 77- — 
over-accumulation of blood immediately behind the 
lesion. In stenosis, the chamber behind cannot 
empty itself in systole with the same ease and in the 
same time as in health, and is thus ill-prepared for 
diastole; in regurgitation it receives a double instead 
of a single blood-supply during diastole, and starts in 
on the systole with an extra load of work to perform. 
In either case the tendency is for the part beyond the 
lesion to get less, the part behind to get more, than 
its share of the nutritive fluid, and is consequently 
toward over-accumulation in the pulmonic or systemic 
veins, or both, and a proportional deficiency in the 
arteries. 

The differences depend on the seat of the lesion < 
and the period of the cardiac revolution during which 
the accumulation takes place. Aortic lesions mani- 
fest their effects primarily on the left ventricle — 
slightly, if at all, on the left auricle, lungs, and right 
cavities as long as the mitral continues to do its work. 
Mitral lesions react at first on the left auricle, the 
thin muscular walls of which can neither withstand 
notable pressure nor furnish compensation; the effects, 
consequently, are promptly reflected back through the 
lungs to the right ventricle, on which more hope can 
be placed; the work of the left heart is at first light- 
ened, though it may ultimately be somewhat increased 
if the mitral disease involve regurgitation. Pulmonary 
valve lesions affect the right ventricle exclusively as 
long as the tricuspid holds tight; tricuspid lesions fall 



- 7 8 - 

upon the very weakest chamber of the whole heart, but 
are, fortunately, singly and alone, of the greatest rarity. 
In general, the thicker walled ventricles are better 
able to withstand increased pressure than the auricles. 
If the increased pressure comes during diastole dilata- 
tion is sure to occur, the strain coming on the relax- 
ing muscles. 

Now, in practice, while the above more or less 
dire results occasionally ensue promptly on the estab- 
lishment of the lesion, they are, as a rule, delayed for 
a longer or shorter period, or may never appear at 
all, though the patient reach or surpass three-score 
years and ten. The reason for this is that the heart, 
like the other viscera, is rarely or never called upon 
to do continuously its maximum amount of work, and 
has a certain reserve power of growth for emergen- 
cies, such as a valvular lesion. If the reserve nutri- 
tive power of the heart in particular, and of the body 
as a whole, has been already exhausted through any 
cause or causes, or if advanced and irremediable tis- 
sue changes have very seriously compromised the 
heart muscle, repair is either impossible or can be but 
slight. Suppose, however, that the condition of the 
patient permits reasonable repair, and that he be- 
comes the possessor of a valvular lesion. The over- 
plus of blood in a heart cavity seems to act as a stim- 
ulus to contraction, which, in its turn, leads to more ac- 
tive circulation and consequently to improved nutri- 
tion and increased growth. Thus the dilatation, which 



— 79 — 
tends to be the immediate local effect in the cavity 
behind the lesion, is limited by hypertrophy; which, 
again, by overcoming the obstruction or pumping a 
larger quantity of blood so that the distal circulation 
still gets its needful supply, though some escapes 
backwards, restores a proper balance of blood-distri- 
bution. The lesion is then, as we say, compensated. 
The heart is not a normal heart, but it accomplishes 
a more or less normal amount of work nevertheless. 
How long it continues to do so, depends upon many 
circumstances, among which may be mentioned the 
degree of the lesion, its seat, its progressive or non- 
progressive character, the age, pecuniary resources, 
and character of the patient, who may or may not 
choose a wise adviser and follow the advice which he 
receives. Of course there is a wide variation in the 
degree of obstruction or regurgitation at an orifice in 
different cases, and there is also a difference in grav- 
ity according to which valve is affected, how it is 
affected, and how rapid has been the injury. It is 
not enough to diagnosticate the seat and character of 
the valve lesion itself; the degree of compensation is 
also to be determined in each case as far as possible, 
and, for prognosis perhaps even more than for diag- 
nosis, the origin of the lesion is of great importance. 
We are now in a position to take up the lesions of the 
valves one by one, and begin with the valve most fre- 
quently affected. 

Mitral Regurgitation, very common and frequently 



uncombined, involves a back current during the ven- 
tricular systole from the left ventricle to the left 
auricle, which thus receives a double blood supply, 
and is subjected to increased internal pressure during 
its diastole, with dilatation as a result. A certain 
amount of hypertrophy can take place in the auricle, 
but not enough by itself to overcome the effects of 
any notable degree of leakage; the heightened press- 
ure is thus thrown back on the right ventricle, in 
hypertrophy of which the main part of compensation 
must lie. The left ventricle, in cases of some stand- 
ing, is usually somewhat dilated and hypertrophied, 
although its work would at first sight appear to be 
lessened. But the blood is delivered to it under in- 
creased pressure from the hypertrophied right ven- 
tricle, tending to dilate its cavity, to stimulate con- 
traction and nutrition, and thus cause hypertrophy. 
Some increase in the size and power of the left ven- 
tricle is truly conservative inasmuch as all its contents 
are not passed on to the aorta, and more or less gen- 
eral arterial anaemia must result unless the whole 
amount dealt with is greater than in the normal con- 
dition. 

In young subjects there may be marked promin- 
ence of the precordial region, but this is rarely notice- 
able when the lesion was not established until the 
bony framework of the thorax had ceased active 
growth. A diffuse and more or less well-marked 
pulsation is to be seen and felt in the apex region, 



— 81 — 

a larger portion of the right ventricle lying in contact 
with the chest wall; and this pulsation may be found 
in the sixth space and well beyond the nipple line, the 
displacement outward depending mainly on changes 
in the size of the right, that downward of the left 
ventricle. A systolic thrill is felt by the hand in the 
mitral area in the smaller proportion of cases. The 
chief increase in the percussion dullness is transverse 
and toward the right, extending in extreme cases 
nearly or quite to the right nipple. Auscultation 
gives a systolic murmur, replacing or accompanying 
the sound, often heard all over the praecordia, but of 
maximum intensity in the mitral area; occasionally 
loudest about the third left interspace; in very rare 
cases, loudest in the back; transmitted to the left into 
the axilla, as far as the vertebral column, even com- 
pletely round the chest; generally soft and blowing in 
character. Exertion may be necessary to develop 
the murmur. The pulmonic second sound is accen- 
tuated to a degree which is of some value in deter- 
mining the freedom of regurgitation and the perfec- 
tion of compensation. If the right ventricle is un- 
equal to the extra work thrown upon it, it does not 
distend the pulmonary artery forcibly in systole, and 
the arterial recoil is relatively slight. The pulse is 
soft, and the patient pale from relative arterial anae- 
mia. The growth of children thus affected may be 
markedly retarded and limited. 

If compensation is defective or fails, the murmur 

6 pp 



— 82 — 

may diminish in intensity, or even disappear, a certain 
amount of force being requisite for its production, 
and pulmonic accentuation becomes less marked or 
absent. The action of the heart becomes rapid, often 
irregular and intermittent; cyanosis appears on the 
scene with other evidences of pulmonary and general 
venous engorgement. Ultimately the tricuspid may 
give way from dilatation and weakness of the right 
ventricle, giving rise to the signs of that condition to 
be later described. Freedom from symptoms and 
ability to withstand exertion are the clearest evidences 
of good compensation. It will be understood that 
the amount of leakage varies widely in different cases, 
with a corresponding variation in the degree of sec- 
ondary changes. The murmur of mitral regurgitation 
due to-structural- lesion can be confused with that .of 
a purely functional or more curable condition. The 
points of distinction between the two come better later. 
Mitral Stenosis is quite common, especially in 
females, but is seldom uncombined with incompetency. 
In the pure state its mechanical effects behind the 
lesion are the same in kind, though greater in degree, 
as in regurgitation; those in front are. somewhat dif- 
ferent. The left ventricle tends to be ill-supplied with 
blood, which it can receive in the normal amount only 
by such increase in the rapidity of the current and 
such lengthening of its duration as will make up for 
the decrease in volume. Enlargement of the left ven- 
tricle is consequently absent. 



-8 3 - 

Here, again, prominence of the praecordial region 
depends chiefly on the age of the patient when the 
damage was done, and on the elasticity of the thorax. 
The impulse is more or less diffused from or beyond 
its ordinary seat, especially toward the left sternal 
border, and a presystolic thrill in the apex region is 
often very marked. If the thrill is less distinct it 
may be felt only when the finger tips are applied very 
gently to the interspace, anything like firm pressure 
seeming to prevent its detection. The increased per- 
cussion dullness of the enlarged right ventricle, and 
perhaps also of the left auricle, can be readily made 
out; and auscultation in typical cases, gives striking 
results. The first sound is shorter and sharper than 
in health, and maybe accompanied by a thump or roll 
which is not easily described but is suggestive to the 
practiced ear. Vibration of the : blood as it passes 
the constricted orifice of the mitral flaps-,, and of the 
curtains themselves is heard by the ear as a murmur; 
usually rough, rasping, or blubbering, in character; of 
greatest intensity in, or a little to the right of, the 
seat of the normal apex; never propagated far and 
sometimes limited to a spot not much if at all larger 
than the chest piece of the stethoscope; prolonged 
diastolic or presystolic in time— that is to say it may 
occupy a large portion of the diastole or be limited to 
that part of it which corresponds to the auricul-ar 
systole — presystolic — ,the contraction of the cavity so 
increasing the blood pressure that a murmur, for 



- 8 4 - 

which the pressure was insufficient during the earlier 
part of the diastole, is caused. The second sound is 
often unusually distinct at or even beyond the apex, 
and may be reduplicated. In many cases all auscul- 
tatory evidence of stenosis is absent, or the murmur 
may come and go. If the stenosis is slight, or if the 
pressure in the pulmonary circuit is low from weak- 
ness of the right ventricle, direct signs are apt to be 
wanting. Accentuation of the second pulmonic at 
the base obeys the same laws as in mitral regurgita- 
tion. Deranged innervation, as shown by irregularity 
and intermittency of the heart's action, is very com- 
mon, often extreme, variable from time to time; the 
rhythm may, however, be perfect. Patients are pale 
and, if the lesion was well established in early life, ill 
developed. The pulse is small and soft. The com- 
pensation is more easily deranged than in incom- 
petency, but the signs of its derangement or rupture 
are essentially the same in kind, and the lesion is less 
compatible with longevity. Regurgitation is usually 
eo-existent and the signs of that lesion may be per- 
fectly manifest while those of the stenosis are ill 
defined or absent. The only murmurs with which 
that of mitral stenosis can be confused are those of 
aortic regurgitation and of tricuspid stenosis. The 
latter is rare and is always combined with mitral 
stenosis; the left ventricular enlargement arid vascular 
signs of the former should promptly clear up any 
doubt which might at first be felt. 



- 8 5 - 

Aortic Regurgitation is a common lesion and often 
uncombined. It involves a backward passage of 
blood from the aorta into the left ventricle during 
diastole, the arterial supply being thus lessened while 
the internal pressure on the relaxing ventricle is in- 
creased by a double current which dilates its cavity 
and demands hypertrophy for compensation. A large 
blood wave is thrown with much force into the aorta, 
the coats of which are distended thereby; but, as soon 
as the pressure is relieved by the completion of the 
systole, a recoil proportional in strength to the dis- 
tending force follows— -unless the elasticity is im- 
paired — and becomes still greater from the fact that 
the blood delivered to the aorta is not all retained 
within it or its branches, some flowing back to the 
ventricle. Thus the mechanical effects of the lesion 
are confined to the left ventricle and the arteries, if, 
and as long as, compensation is established. The 
cardiac physical signs are : prominence of the prae- 
cordia, sometimes very marked; a powerful heaving 
impulse; and an apex beat decidedly lower than and 
more or less to the left of the normal seat, perhaps in 
the seventh space and anterior axillary line. Some- 
times a diastolic thrill can be felt at the base. The 
change in the size of the left ventricle brings this por- 
tion of the heart forward and downward in the main, 
increasing the vertical diameter. Percussion confirms 
the results of inspection and palpation and shows that 
the right border is little, if at all, changed. Ausculta- 



— 86 — 

tion gives a prolonged, generally soft and blowing, 
murmur throughout the diastole over more or less of 
the cardiac and immediately adjoining regions. The 
seat of maximum intensity varies, being sometimes in 
the aortic area, sometimes below this point over mid- 
sternum, rarely not far below the clavicle; not infre- 
quently the murmur is comparatively feeble, or even 
inaudible, in the aortic area, but loud and distinct 
near the fourth left costal cartilage; these latter are 
the cases in which mitral stenosis might be confused 
with aortic insufficiency by a superficial observer. 
The murmur is always propagated downwards in the 
direction of the current producing it, toward the ensi- 
form cartilage. It may replace or only obscure the 
second sound, according to its intensity, the transmis- 
sion of the pulmonic second, and the involvement of 
all the aortic segments, or of only one or two; it is 
occasionally heard in the back. The first sound at 
the apex also varies in character. It may be very 
loud and booming; rather impure; accompanied by a 
murmur not dependent on mitral regurgitation appar- 
ently, but on vibrations in the valves set up by the 
very powerful ventricular contractions; or it may be 
lost altogether. The vascular signs are striking and 
distinctive, perhaps sufficiently so to permit diagnosis 
at the first glance without removal of the clothing 
from the chest. The visible arteries, and alsa 
some which are usually not visible, rise rapidly in 
systole and fall with equal rapidity in diastoleJ 



- 8 7 - 

If, as is apt to be the case when the lesion is 
of high degree and long standing, the arteries 
have become lengthened and tortuous, a lateral 
movement takes place in them, as may perhaps be 
most distinctly seen in the brachial, the temporal, or 
with the ophthalmoscope in the central artery of the 
retina. The aorta may then become permanently dis- 
tended and easily felt in the supra-sternal notch, while 
atheromatous changes in the arteries generally, as well 
as in the aorta itself, are favored by the abnormal 
differences of tension to which they are subjected. 
The sensation conveyed to the finger placed on an 
artery corresponds exactly with the above. The pulse 
is quick, large, rises and falls rapidly — the water-ham- 
mer, or Corrigan's pulse. By laying the fingers across 
the wrist firmly the radial and ulnar, and even the 
interosseous, may simultaneously be felt strongly 
pulsating. These peculiar features of the pulse may 
be intensified by raising the arm vertically above the 
head of the patient, thus favoring the collapse by the 
addition of the force of gravity exerted on the column 
of blood between the wrist and the heart. Over the 
carotids and subclavians a systolic thrill may often be 
felt, and heard as a murmur; this does not necessarily 
indicate stenosis, but may be caused simply by the 
violence of the systole, just as an apex systolic mur- 
mur, under similar circumstances, may or may not be 
due to mitral regurgitation. Over the peripheral arter- 
ies generally, often even those of relatively small size, 



— 88 — 

a systolic sound is to be heard, and in strongly marked 
cases a double sound may be present in the crural. 
Capillary pulsation can often be beautifully seen by 
pressing a glass microscope slide against the mucous 
membrane of the everted lower lip; or after successive 
strokes with the finger on the skin, say of the fore- 
head. It will be understood that many of the signs 
depend directly on the compensatory hypertrophy, 
and grow less distinct, or disappear with its decline 
and failure. A patient with aortic regurgitation has 
often a ruddy appearance and is capable of great 
muscular exertion without distress. Compensation is 
lost through failure of the left ventricle when dilata- 
tion advances and the mitral gives way; downward 
progress may be arrested for a time by hypertrophy of 
the right ventricle. Finally the tricuspid may begin 
to yield and the picture is identical with that of loss of 
compensation in mitral lesions. When compensation is 
ruptured in aortic lesions the outlook for its restoration 
is not as good as in mitral cases, though this rule, 
like all others, has its exceptions. 

Aortic Stenosis is rarely found alone, being com- 
bined in varying proportion with regurgitation. When 
the valve segments are so fused that they form a sort 
of diaphragm with a central orifice, the amount of 
blood which flows back into the left ventricle cannot 
be very large. The lesion involving an impeded pas- 
sage of blood from the left ventricle into the aorta, 
the increased pressure within the cavity of the former 



- 8 9 - 

tends to dilate it; but this dilating force is exerted 
against the contracting, not as in regurgitation against 
the relaxing muscle, and is consequently at a relative 
disadvantage. This tendency can be overcome solely 
by hypertrophy, which, to be truly compensatory, 
must be in exact proportion to the degree of obstruc- 
tion. Thus the wall of the left ventricle may attain 
the thickness of an inch. Dilatation is measured 
rather by the freedom of a combined incompetency. 
Inspection and palpation may show some promi- 
nence of the cardiac region — an apex beat lower than, 
and somewhat to the left of, the normal seat; a strong 
and heaving impulse; occasionally a systolic thrill in 
the aortic area. Percussion is chiefly important as 
showing that the right heart is not enlarged. Auscul- 
tation gives a systolic murmur, usually harsh and 
sometimes musical, loudest at and above the aortic 
area, transmitted into the aorta and great arterial 
trunks given off from the arch, sometimes to be fol- 
lowed down the left vertebral groove a greater or less 
distance in the dorsal region. The aortic second 
sound is feeble, if not replaced by a regurgitant mur- 
mur. The first sound at the apex is prolonged and 
intensified. Owing to the constriction at the outlet, a 
longer period is required for the emptying of the ven- 
tricle; the pulse is therefore slow, rises gradually 
under the finger, is rather hard, and usually regular. 
The steps of failing compensation are essentially the 
same as in aortic regurgitation. 



— 9 o — 

Mere roughening of the cusps, or of the aorta 
itself, may give rise to a murmur and other signs in- 
distinguishable from those of stenosis, especially if in- 
creased resistance in the peripheral circulation, due to 
arterial degeneration, renal cirrhosis, or other cause, 
has induced enlargement of the left ventricle. Even 
careful weighing of all the features of a case may not 
clear away all doubt as to the presence of a moderate 
degree of stenosis. 

Lesions of the Right Heart can be discussed 
more briefly, in that they are not only far more rare 
than those of the left, but underlying principles should 
be so thoroughly understood by this time as to permit 
the taking of much for granted. As combined lesions 
they are generally secondary to those on the left side. 
Congenital defects will receive brief separate consid- 
eration. 

Tricuspid Regurgitation is of considerable clinical 
importance, forming, as it does, one of the last steps 
of compensatory loss in left-sided muscular failure, of 
valvular or other origin. Behind this valve is practi- 
cally no compensatory force. The valve may or may 
not be structurally altered; usually it is not, leakage 
being due to failure of the flaps to close, simply from 
dilatation of their ring of insertion, and feebleness of 
the muscular contraction. Long-standing and ad- 
vanced lung disease, emphysema, and fibroid phthisis, 
may underlie the condition, as well as valvular dis- 
ease of the left heart. 



— 9i — 
The apex beat is usually diffused to the right and 
left, and is often undulatory; percussion shows en- 
largement, especially toward the right and over the 
right auricle; the murmur is systolic, loudest at the 
right apex, not far propagated or heard in the back. 
It may be distinguished from a coexistent mitral re- 
gurgitant murmur by a difference in pitch and quality; 
the pulmonic second is not generally accentuated. 
The clinching evidence, however, is to be looked for 
outside the heart. The systolic blood-wave is trans- 
mitted through the incompetent orifice to the auricle, 
and thence to the contents of the veins emptying 
therein. The hepatic veins, being devoid of valves, 
offer no impediment to the wave, and the liver itself 
may then be felt to pulsate synchronously with the 
heart; this sign must not, however, be confounded 
with the motion which an enlarged right ventricle, 
separated from the left lobe of the liver only by the 
diaphragm, sometimes imparts to that organ. The 
external jugular veins, on the other hand, have valves 
beyond which the pulsation cannot extend unless they 
also have become incompetent, the delicate walls 
yielding to the greatly increased pressure. A true 
pulsation of the jugulars is to be distinguished from 
false pulsation and undulation by compressing the 
vein by the finger; if the motion be caused by the 
contraction of the right ventricle, it will persist be- 
tween the finger and heart after compression; it thus 
affords an important and almost conclusive sign of 



— 9 2 — 

tricuspid leakage. Respiratory distension and col- 
lapse of the cervical veins ceases when the breath is 
held. Occasionally the venous valves are seated 
"nearly or quite an inch above the mouth of the vein, 
and pulsation, while the valve still holds, may then be 
seen just above the clavicle. Distension of the jugu- 
lars from tricuspid insufficiency can often be increased 
by firmly pressing tne liver upward and backward. 

Tricuspid Stenosis is always combined with mit- 
ral stenosis, and often with regurgitation at one or 
both orifices; there is also at the same time aortic 
stenosis in 25 per cent, of the cases according to Fen- 
wick. Under these circumstances the only physical 
sign directly pointing to the presence of the lesion is 
a presystolic murmur at the right apex differing in 
pitch and quality from that in the mitral area. It has 
once been the good fortune of the writer to diagnosti- 
cate this complex state of affairs with adherent peri- 
cardium, hepatic cirrhosis, and slight granular kidney, 
and to have the diagnosis confirmed in full by 
autopsy. The tricuspid presystolic murmur was 
heard only during a brief period some three years be- 
fore death. During these years the woman sup- 
ported herself much of the time, entering the hospital 
several times to be patched up, but the tricuspid and 
mitral presystolic murmurs could not again be differ- 
entiated. 

Pulmonic Regurgitation is a condition of theoreti- 
cal rather than clinical interest. Its diagnosis could 



— 93 — 
rest only on the presence of a diastolic murmur at and 
below the base of the heart, and loudest near the pul- 
monic area, with right sided enlargement, all proof of 
aortic leakage and of left sided enlargement being at 
the same time lacking. 

Pulmonic Stenosis is less rare than insufficiency, 
and usually congenital. Its signs are a systolic mur- 
mur loudest in the pulmonic area and not transmitted 
into the great vessels; but associated with right sided 
enlargement, generally youth, and a history or the 
presence of cyanosis on, or independently of, exer- 
tion. If it were more common it might frequently 
lead to error, the seat and time of the most conspicu- 
ous anaemic murmur being the same. 

Congenital Valvular Lesions may be due either to 
endocarditis during foetal life, to malformation, or to 
both; inflammation being more prone to attack a mal- 
formed than a normal valve. The right heart is their 
favorite seat, and pulmonic stenosis is by far the com- 
monest lesion. If this is more than slight, compensa- 
tory relief to the circulation must be had by means of a 
patent foramen ovale ductus arteriosus, or inter-ventri- 
cular septum, the passage of the blood through which 
may produce vibration and murmur precisely as through 
a constricted or incompetent valvular orifice. This 
fact introduces an element of doubt into the interpreta- 
tion of congenital murmurs from which acquired lesions 
of the heart are free. The history of the case may 
hence assume greater importance than in those cases 



— 94 — 

with acquired lesions. In a young person of more or 
less stunted development, who from earliest childhood 
has been cyanotic and short of breath, with clubbed 
fingers and toes, and who is free from any history of 
rheumatism or rheumatic pains, the other physical 
signs of valvular disease point with almost absolute 
certainty to lesions of the right side of the heart 
dating from intra-uterine life. There are again other 
cases, widely differing in character from those just 
mentioned, which can safely be classed as congenital. 
A young person, namely^ may present none of the 
rational signs of heart disease, and the heart may be 
but little if at all enlarged, and yet a persistent and 
very loud murmur may be heard, at. the base: of the 
heart, over. a large portion of the chest, nay on the 
top of the--- head .and almost everywhere over the 
trunk, not. attributable to aneurism- or any other cause 
outside of the heart itself; it may also be heard at a 
distance from the chest and. give rise to an extended 
-thrill. Jn such case the. defect is either a slight one 
— it is always to be remembered that the loudness of 
a murmur is no index of: its gravity — or the. compen- 
sation is so perfect that no inconvenience results, per- 
haps for a long period of time. 

Having now concluded the physical signs and 
diagnosis of chronic valvular lesions we must next 
consider: 



— 95 — 

ACUTE ENDOCARDITIS, SIMPLE AND MALIGNANT. 

Acute Simple Endocarditis is ordinarily to be diag- 
nosticated rather by the circumstances under which 
the physical signs appear, than by the physical signs 
themselves. If, for instance, during the progress 
of acute rheumatism an endocardial murmur de- 
velop at the mitral or aortic area, persist, and is 
followed by appropiate enlargement of the heart, it is 
clear that inflammation of the valvular endocardium 
was present. If> -under the same circumstances, a 
mitral murmur comes, lasts for a variable time}- but 
disappears without leaving traces behind, one cannot 
be sure whether the murmur was due to inflammation 
of the endocardium, of the myocardium, or simply to 
dynamic weakness. A later development of> a valvu- 
lar lesion without a- recurrence of the /rheumatic 
attack would settle the. question in favor of. endo- 
carditis. • :■-.: - •>..:.!..;. f . 

Malignant Endocarditis isr.an acute .process, the 
pathological relations of which to the simple form 
are still unsettled. The physical signs: in the heart 
itself are in no wise distinctive, and may; be very 
slight or even entirely absent. For a description of 
the symptoms which often warrant a positive diag- 
nosis this is not the place. The writer has seen two 
clear cases, one with post mortem, in which malignant 
endocarditis was the result of gonorrhoea. 



-96- 

D. CONDITIONS CHARACTERIZED SIMPLY BY ABNOR- 
MAL RATE OR RHYTHM, BY MURMURS, OR BY 
MODIFIED SOUNDS — FUNCTIONAL DIS- 
ORDERS OF THE HEART. 

The above peculiarities of cardiac action have 
been mentioned many times in connection with the 
various organic lesions of the organ. They are often, 
however, encountered in hearts which are free from 
serious or permanent changes; altered rate and rhythm 
chiefly as a result of faulty innervation, murmurs in 
connection with altered blood states and transitory 
weakness of the heart muscle. 

The action may be abnormally slow— 30 or even 
less; or abnormally rapid — 160 to 200, under the in- 
fluence of causes which are usually transitory. Less 
extreme degrees of slowness or rapidity may be of 
long duration, as in the habitually slow pulse of cer- 
tain individuals, or in exophthalmic goitre where the 
heart may or may not be structurally sound, though 
its rate is greatly quickened. Irregularity and in- 
termittency are often of little or no consequence, as, 
to take an extreme case, in a sleeping child. 

In most cases of rate and rhythm change the 
stethoscope over the heart should control the evidence 
of the radial pulse, and it is advisable in cases which 
are not perfectly clear to suspend positive diagnosis 
until examination can be repeated. The habits, gen- 
eral condition of the patient, state of all his other 



— 97 — 
organs and tissues, etc., must receive careful consid- 
eration; and organic lesions of the component parts 
of the heart itself must be excluded. Thus only can 
we escape the serious blunder of mistaking myo- 
carditis, fatty degeneration, or other grave structural 
change for functional disorder. A full discussion of 
this branch of our subject would lead us far beyond 
the scope of this little work. 

The great Laennec recognized the fact that 
hearts over which murmurs are heard during life are 
sometimes found structurally intact after death, and 
much ingenuity and discussion have been expended 
.on the elucidation of the mechanism of these mur- 
murs without enabling us yet to arrive at perfectly 
clear knowledge. The tendency is to-day to attribute 
nearly all murmurs in the mitral area to regurgita- 
tion, the important practical question thus becoming 
whether in a given case the murmur is due to remedi- 
able or to irremediable causes, or, as Dr. George 
Balfour puts it, whether it is curable or incurable. A 
structural valvular lesion due to endocarditis which 
has passed the acute stage is, with few exceptions, 
permanent; an acute lesion may however, either un- 
dergo complete repair, or it may seem to do so but 
really lay the foundation of mischief which betrays 
itself long after. It will thus be seen that we are 
obliged to content ourselves with a classification of 
apex murmurs which is clinical rather than pathol- 
ogical. 

7 PP 



- 9 8- 

The basic functional murmurs, so called, are the 
subject of less dispute, and are generally associated 
with anaemia, primary or secondary, and often with a 
venous hum in the neck which may be heard on one 
side only, or on both simultaneously. Their favorite 
seat is the pulmonic area; they are systolic, and rarely 
far transmitted. They may be heard less distinctly at 
the apex; sometimes anaemic murmurs are heard only 
there, and not at all at the base. In their diagnosis 
the same precautions must be taken as in the inter- 
pretation of changes in rate and rhythm. 

One other class of murmurs, the cardio-respira- 
tory, deserves mention as possibly leading to error. 
They are associated with some phase of the respira- 
tory act, are systolic in time, disappear or are greatly 
modified when the breath is held, and are usually 
loudest at the end either of inspiration or expiration. 
They are not necessarily connected with appreciable 
changes in the lungs, and are analogous to the sub- 
clavian systolic whiff heard in some cases of apex 
phthisis and pleurisy, as well as in the absence of 
those diseases. 

The following table may aid in the diagnosis of 
this whole class of murmurs: 



THE SERIOUS MURMURS. 

Occur at any time in the car- 
diac revolution, either at 
the base or apex. 



THE NON-SERIOUS MURMURS. 

Are systolic in time, and more 
common at the base. 



— 99 



THE SERIOUS MURMURS. 

Are apt to be associated with 
rheumatism or its history, or 
with degenerative changes 
in other parts or organs. 

Have definite lines of propa- 
gation. 

Are persistent. 

Involve more or less well- 
marked enlargement of the 
heart. 



THE NON-SERIOUS MURMURS. 

Are usually associated with 
anaemia, fevers, nervous ex- 
citement, or respiration. 

Have no definite lines of pro- 
pagation. 

Are usually transitory. 

Involve no marked enlarge- 
ment of the heart. 



CHAPTER III. 

THE PERICARDIUM. 

Pericarditis, inflammation of the pericardium, is 
quite analogous in itself and in its results to inflamma- 
tion of other serous membranes, and especially of 
the pleura, though the physical signs differ, of course, 
in some important respects. Just as in pleurisy, so here, 
we must distinguish between local, dry, and adhesive 
pericarditis, and that which is attended by appre- 
ciable effusion. A division into the acute and chronic 
forms is less important from our point of view. 

In the dry form the pericardial surfaces no longer 
glide freely upon one another as the heart contracts, 
dilates, and rotates. Inspection shows nothing more 
than, perhaps, quickened respiration with a rapid or 
irregular action of the heart; palpation may show 
tenderness of the praecordia, and friction fremitus; 
percussion is negative. The distinctive physical signs 
are auscultatory, and the chief of these is friction, 
most commonly heard over the front of the right ven- 
tricle where it nearest approaches the chest wall, 
double, — to and fro — systolic and diastolic, superficial, 
intensified by pressure with the stethoscope, not al- 
ways perfectly synchronous with the heart sounds, 
sometimes single. The friction may obscure the heart 
sounds, or, if the action is rapid, these are apt to be 



IOI 

short and weak; disordered rhythm is common. 
Pericardial friction should persist when the breath is 
held, but even this test does not distinguish with cer- 
tainty a pericardial rub from one arising in the pleura 
overlying the heart, and excited by the movements of 
that organ. Pericardial inflammation is often sec- 
ondary to left pleurisy, and the co-existence of the 
two enhances the difficulty of the diagnosis. But 
acute pericarditis may be entirely latent as far as 
direct physical signs and symptoms go. The writer 
has examined the cardiac area with the greatest care 
twice daily for more than a week, having good reason 
to believe that dry pericarditis was present, without 
hearing friction; yet the autopsy showed general 
recent adhesions. 

Adherent pericardium involves, of course, oblit- 
eration of the cavity either in whole or in part, is apt 
to derange the function of the organ, and may lead 
later to advanced myocarditic changes. If the adhes- 
ions are limited to the visceral and parietal layers of 
the sac their presence cannot be diagnosticated dur- 
ing life. They may give rise to no symptoms at all, 
or any symtoms to which they do give rise are in no 
way distinctive. If, however, the external surface of 
the pericardium is densely adherent to the chest wall 
in front, suggestive signs may be present. Such are 
systolic retraction of the apex region with diastolic 
rebound; recession of the epigastrium on deep inspir- 
ation, the area of cardiac flatness and the position of 



102 

the apex being unchanged thereby; immobility of the 
heart on change of position of the patient; and dias- 
tolic collapse of distended veins in the neck. The 
first of these signs, systolic retraction of the chest 
wall, cannot be looked for if the costal cartilages are 
ossified; and may be ill-marked or absent if the 
heart's action is feeble. 

Pericardial Effusion. — The pericardium is a 
closed sac which extends up a certain distance on the 
great vessels, and is thence reflected. As fluid is 
thrown out it will naturally, unless limited by adhe- 
sions, occupy the lowest portion of the sac containing 
it, and, as it increases, will tend to lift the heart up- 
ward and forward and to tilt it to the left. Previous 
enlargement or fixation of the heart, or emphysema- 
tous, fixed, or consolidated edges of the lung in the 
cardiac region, will modify this tendency in ways 
which are readily understood. It will also be seen 
that the physical signs must vary according to the 
amount of the effusion; and that, if this is absorbed, 
they will during absorption follow an inverse order of 
sequence to that which characterized the stage of in- 
creasing effusion. 

Inspection shows marked prominence of the 
praecordia only in patients with elastic chest-walls, 
notably in young subjects and in very large effusions; 
in the latter case there may be distinct bulging at the 
epigastrium, with dislocation of the liver and of other 
organs lying immediately below the diaphragm. The 



apex beat is raised and moved somewhat outwards, 
being seen sometimes in the fourth, or even in the 
third, spa,ce; it may be indistinct or absent, according 
to the quantity of the fluid and the presence or ab- 
sence of complications in the heart itself or the adja- 
cent portion of lung. 

Palpation confirms the results of inspection, and 
may detect friction over the superficial portion of the 
sac above the level of the fluid. The seat and intens- 
ity of the friction may undergo change with change 
in the position of the patient. Percussion show r s in- 
crease in the flat and dull areas which, in large and 
uncomplicated effusions, presents a characteristic 
shape. The lowest is the most distensible part of the 
pericardial sac; flatness begins, therefore, to increase 
here, and, with a mounting effusion, grows laterally 
and rises- upward till it assumes a more or less well- 
marked pear shape, the smaller part of the pear cor- 
responding to the reflection of the sac from the great 
vessels. The experiments of Rotch indicate that flat- 
ness in the fifth right interspace extending as much 
as three centimetres beyond the sternal border occurs 
in pericardial effusion, but practically never in en- 
largement of the heart. Dislocation may produce it, 
but this possibility is really excluded by the absence 
of any cause for such dislocation. Auscultation shows 
a gradual ascent and disappearance of the friction if 
the case be under observation and correctly diagnos- 
ticated from the start. The heart-sounds become 



— 104 — 

muffled, distant, and indistinct, the first being short 
and valvular owing to the embarrassment and weak- 
ening of the ventricular contractions resulting from 
the disadvantage at which the heart works, and per- 
haps coexistent endo- and myo-carditis. Endocardial 
murmurs may or may not be present; if they, and left 
dry pleurisy, are both associated with pericardial fric- 
tion, the auscultatory phenomena may be of a highly 
complicated character. 

Orthopnoea, cyanosis, quick, and rhythmically dis- 
ordered action of the heart may be present according 
to the severity of the inflammation, the rapidity and 
the amount of the effusion, and the co-existence of 
complications. The paradoxical pulse, absence of the 
pulse-wave during inspiration, is not strictly con- 
fined to pericarditis. Large pericardial, like large 
pleural effusions, may be remarkably latent as far as 
symptoms are concerned; but the latency has, of 
course, no influence on the direct physical signs. 

The chief source of error in diagnosis is the 
dilated and weak heart. 

Hydropericardium, or dropsy of the pericardium, 
gives rise to the same physical signs as inflammatory 
effusion except that friction is less common while 
dropsical transudation is elsewhere more constant in 
cases of the former. 

Rheumatism, left pleurisy, and other causes of 
pericarditis are to be taken into account in establish- 
ing the diagnosis. 



— i<>5 — 

Pneumo-hydro- or pnewno-pyo -pericardium is a rare 
condition the nature of which is sufficiently indicated 
by its name. The liquid seeks the lower, the air the 
upper portion of the sac, and the two change place 
with change in the position of the patient unless ad- 
hesions prevent. Splashing and churning sounds are 
heard on auscultation over the cardiac area, in more 
or less regular synchronism with the heart beat. 



CHAPTER IV. 

THORACIC ANEURISM. 

Aneurismal dilatation of the aorta may occupy- 
any portion of the vessel, but is most common in the 
ascending, and thence onward progressively diminishes 
in frequency; it may involve only part of the circum- 
ference —saccular, the whole circumference of a lim- 
ited segment —fusiform, or the dilatation of the aortic 
arch may be pretty general as the result of atheroma 
and aortic regurgitation; the latter should not, strictly 
speaking, be classed as aneurismal. The affection 
befalls by preference the male sex and early middle 
life, men during this period being more exposed to 
the strain of muscular exertion acting in conjunction 
with weakening of the vascular walls due to degenera- 
tive changes set up by syphilis and the abuse of 
alcohol. A more or less local yielding of the arterial 
coats to the blood pressure tends to increase in size 
and to form a tumor, pulsating synchronously with 
the heart, displacing, pressing on, or destroying, 
the tissues and parts in its immediate vicinity. The 
symptoms and signs must, therefore, vary with and 
depend on the portion of the aorta affected, the size 
of the aneurism, and the aspect of the vessel from 
which it springs. It is customary to divide the signs 



— 107 — 

into two main classes; the direct, those due immedi- 
ately to the tumor itself; and the indirect, those due 
to the pressure which it may exert on neighboring 
structures or parts. The first class is encountered 
especially when the aneurism springs from the anter- 
ior or lateral portions of the ascending or transverse 
aorta and grows more or less forward, the latter 
when it extends inward and backward toward the root 
of the lungs or rises from the inner or posterior aspect 
of the vessel. One class only of signs, or both simul- 
taneously, may be represented. 

i. Direct Signs. — Inspection reveals pulsation or 
a pulsating tumor under, to the right, or under and 
to the right of the sternum, near to or above the base 
of the heart. The pulsation is synchronous with the 
cardiac impulse, which occupies its normal seat unless 
the heart be enlarged or displaced from some other 
cause. It is important to remember that an aneurism 
does not usually in itself throw extra work on the 
heart and thus lead directly to enlargement of that 
organ, though arterial degeneration may be an under- 
lying cause of both. The pulsation may be limited 
in extent, or more diffuse and prominent, according 
to the size of the aneurism and the amount of ab- 
sorption of the sternum and ribs which it has caused. 

Palpation may detect a pulsation which is not 
visible, or confirms and enlarges the results of inspec- 
tion. The pulsation is expansile, equal alike at the 
summit and sides of the tumor, which is to a degree 



— 108 — 

compressible, especially if it is not lined with a thick 
layer of laminated clot. A thrill, usually systolic, is 
not uncommon. 

Percussion gives dullness or flatness over the 
pulsation or pulsating tumor according to its size and 
the relation which it bears to the lung tissue; or there 
may be localized dullness although inspection and 
palpation are negative; or percussion also may be 
negative. The reasons for these differences are 
obvious. 

Auscultation also yields variable or negative re- 
results. In the first place, nothing abnormal may be 
heard; secondly, normal heart sounds of unusual in- 
tensity for that place may be found over the seat of 
the aneurism, the second sound being especially dis- 
tinct; thirdly, there may be a murmur or murmurs, 
and these may be generated either in the sac itself or 
at one or more of the cardiac orifices. A murmur 
originating in the sac is apt to be systolic, but may be 
double; one arising at a cardiac orifice is generally 
associated with enlargment of the heart unless it is 
due simply to a little roughening of the aortic valves. 
The results of auscultation alone are, therefore, not 
to be much depended on. 

2. Indirect Signs. — These vary greatly with the 
direction in which pressure is exerted, and may con- 
sequently afford testimony of extreme value as to the 
presence and seat of a thoracic tumor while most of 
them throw no special light on its nature. Re- 



— 109 — 

tardation of the systole in the peripheral arteries as 
compared with the apex beat may occur in some cases 
of aneurism of the ascending aorta; or retardation, 
weakening, or obliteration, may be noted in the right 
or left radial as compared with its fellow if the aneur- 
ism involve the innominate, or is seated between the 
innominate and the left subclavian, or involve the 
latter, respectively. Such delay or weakening of the 
pulse, can generally be appreciated by the finger. 

Pressure on the left innominate vein or the in- 
ferior cava may be caused if the transverse or ascend- 
ing portions are involved, and is manifested by dis- 
tention of the branches emptying into these trunks, 
turgescence of the face, oedema, etc. 

Pressure on the left recurrent laryngeal nerve 
which winds round the transverse portion of the arch 
is common in aneurisms of that part. The corres- 
ponding vocal cord may be either paralyzed or spastic 
according as the pressure irritates the nerve or de- 
stroys its conducting power, and aphonia, hoarseness, 
and stridor may result. The laryngoscope is then an 
important aid to diagnosis. 

Pressure on a primary bronchus may also cause 
stridor, but without laryngoscopic change; also unila- 
teral dullness on percussion, enfeeblement of the 
respiratory murmur, and whistling respiration. 

Pressure on the oesophagus is liable to give rise 
to dysphagia, and the seat of obstruction may some- 
times be localized by auscultation while the patient 



— no 

swallows. The passage of a bougie may, in such a 
case, result in rupture of the sac. 

Pressure on the sympathetic may cause inequality 
of the pupils and vaso-motor changes on one side of 
the face and neck, both together being much more 
suggestive than either one alone. 

Pressure on the bodies of the vertebrae, the 
sternum, and the ribs, tends to cause erosion and ab- 
sorption of the bone and cartilage; vertebral pressure 
is especially apt to be accompanied by severe and 
boring pain, which, in the appropriate part of the 
dorsal spine, should always awaken suspicion. 

In cases of more or less general dilatation of the 
aorta without the formation of a true aneurismal sac, 
the pulsation of the transverse portion may be felt by 
pressing the finger behind the sternal notch, and per- 
cussion is usually dull over the upper piece of the 
sternum. 

Aneurism of the Innominate or Subclavians is seated 
higher and farther to the right or left than one spring- 
ing from the aorta itself. 

If a tumor is present the equal expansion in all 
directions with the cardiac systole is the most import- 
ant evidence of its aneurismal nature. All the other 
signs, direct or indirect, may be produced by any 
solid intrathoracic tumor which may border or en- 
croach on any portion of the course of the aorta. 
But aneurism far surpasses in frequency all other 
varieties of tumor in this situation; and, in doubtful 



— Ill — 

cases, the predisposing causes of aneurism are to be 
taken into account. Aneurism, moreover, does not 
impair the general health and nutrition unless it wears 
the patient out by pain or prevents sufficient inges- 
tion of food through pressure on the oesophagus. 
Aneurism, again, is more liable to undergo temporary 
variation in size — from variations in the blood-press- 
ure behind it — than any other solid tumor, with a cor- 
responding and more or less rapid change in its 
indirect signs and symptoms. 

Pulsating pleurisy, almost invariably left-sided; 
malposition of the aorta from rickets; malformation 
of the chest; a dilated auricle; unusual retraction of 
the lung normally overlying the heart; and lung con- 
solidation, especially near the pulmonary artery, are 
all possible sources of error. 

Aneurism of the Abdominal Aorta gives rise to much 
the same direct signs as that of the thoracic; but the 
anatomical relations of the sub-diaphragmatic portion 
of the vessel are such that the chief indirect symptom 
is pain from vertebral pressure and erosion. A solid 
tumor— gastric cancer, for instance — may overlie the 
vessel and transmit its pulsation; but lateral expan- 
sion is in such a case lacking, and the pulsation may 
disappear or become less distinct when the patient is 
put on his hands and knees. In very thin persons 
the accessibility of the aorta may occasion serious 
error, which is also not infrequently caused by unusu- 
ally marked pulsation of neurotic origin in the 



healthy vessel or anteroposterior spinal curva- 
ture. Every physician has seen great unhappiness 
caused by the lack of sufficient care in excluding the 
above innocuous conditions. 



CHAPTER V. 

PHYSICAL EXPLORATION OFTHE LIVER, SPLEEN, 
STOMACH, AND PANCREAS. 

Changes in these organs, which lie in more or 
less close juxtaposition to those of the thorax are 
liable to modify the physical signs of the latter and 
thus lead to error. A brief consideration of such 
changes seems, therefore, to be in order. Here, 
again, accurate knowledge of the normal anatomical 
relations as well as of the limits of normal variation is 
of prime importance. 

THE LIVER. 

The liver occupies chiefly the right upper ab- 
domen, lying immediately beneath the arch of the 
diaphragm, and, speaking broadly, filling the whole 
space between the diaphragmatic arch and the right 
costal border, though in the back and side it extends 
only to the eleventh rib. The left lobe extends into 
and across the epigastrium, covered in its upper por- 
tion by the heart, in its lower to a varying degree by 
the stomach. 

Percussion and Palpation in Health. — The upper 
border can be outlined with considerable accuracy 
anteriorly and laterally. In the front dullness begins 
at the lower edge of the fifth rib, flatness on the sixth, 

8 pp 



— H4 — 

these lines running parallel and nearly horizontal out- 
ward and backward and intersecting the ribs success- 
ive^ as these run downwards and forwards. These 
lines are naturally somewhat modified by the ascent 
and descent of the diaphragm in forced expiration 
and inspiration. The lower border can generally be 
distinguished throughout nearly its whole extent from 
the resonant digestive canal by very gentle per- 
cussion. 

In the perfectly normal condition the organ can- 
not be felt. The gall bladder is not accessible to per- 
cussion or palpation. 

Percussion in Disease. — Modifications in the size 
of the liver may be apparent or real, general or local. 
The modes in which disease above the diaphragm 
may alter the relations of the organ have been already 
indicated, but the whole subject of change in hepatic 
percussion is well epitomized by Weil as follows: 

i. The low r er border is normal. 

(a). The upper border is high; enlargement of 
the liver upward; moderate pleural effusion, the dull- 
ness of which joins that of the liver; enlargement of 
the liver with coincident displacement upward, as in 
hypersemia or amyloid disease with ascites. 

(b). The upper border is depressed; moderate 
emphysema. In such a case the height of the dull 
hepatic zone above the pneumono-hepatic line is 
normal or increased. 

2. The lower border is depressed. 



— n5 — 

(a). The upper border is raised; great enlarge- 
ment of the liver; large pleural effusion. 

(b). The upper border is normal; enlargement of 
the liver; anomalous position of the organ, as in fatty 
or corset liver. 

(c) The upper border is depressed; great emphy- 
sema; pneumothorax; in either case the relative dull- 
ness above is wanting or diminished. 

3. The lower border is too high. 

(a) The upper border is high; displacement of 
the liver upward. 

(b). The upper border is normal; atrophy of the 
liver; obliquity of position without marked displace- 
ment. 

4. The hepatic flatness is absent. 

Oblique position of the liver with meteorism and 
ascites; intervention of intestinal coils containing gas, 
or of free gas in the peritoneum, between the convex 
surface of the liver and the abdominal wall. 

5. Change of the hepatic flatness to the other 
side of the body in cases of visceral transposition. 

Great enlargement may give rise to dullness and 
feeble respiration in the right, or even in both backs. 
This the writer has seen exemplified in a case of 
hydatids of the liver as well as in other affections. 

The lower border of the healthy organ may be 
depressed to a greater or less degree by thoracic dis- 
ease, or by sub-diaphragmatic abscess, for instance; 
or it may become accessible to touch as a result of 



— n6 — 

enlargement, either general or local. If the abdo- 
minal wall is lax the whole contour of the lower 
border anteriorly and laterally, the shape and density 
of its edge, and the character of a varying portion of 
the surface as regards smoothness or roughness, can 
be well made out. The descent of the edge against 
the fingers on deep inspiration is often wonderfully 
distinct, and peritoneal friction can sometimes be felt 
over the liver when the portion of the membrane in- 
vesting that organ is not too acutely inflamed. The 
friction may also be heard with the stethoscope. In 
some cases of ecchinococcus disease the hydatid 
thrill may be felt. In many cases the hyper- 
aesthetic rigidity of the abdominal muscles, ten- 
sion of' the hepatic capsule, or actual inflammation, 
render it either difficult or impossible to obtain posi- 
tive results from palpation, which should always be 
used as a control method to percussion in cases of 
suspected hepatic enlargement or displacement. Re- 
peated examination may remove doubts engendered 
at first. In cases of moderate ascites the fingers, by 
a quick but gentle thrust, can often be made to pene- 
trate the fluid and reach the surface of the enlarged 
liver; if the ascites is great and the abdominal wall 
tense an examination immediately after paracentesis 
may be necessary in order to enable us to determine 
the size and surface of the liver. 

The determination of the cause of either atrophy 
or enlargement involves a careful study of the special 



— ii7 — 

features of the change, of the history of the case, and 
of the rest of the organism. It therefore does not 
lie within our province here. 

A distended gall bladder may become accessible 
to sight, percussion, and touch; forming a rounded 
tumor, dull on percussion, elastic or fluctuant, in the 
angle between the lower edge of the liver and the 
outer edge of the right rectus abdominis muscle. In 
some cases the tumor can be diminished in size by 
pressure, the contents thus being forced out. 

THE SPLEEN. 

This organ lies deep in the left hypochondrium, 
Its long diameter being directed obliquely from above 
and behind, downwards and forwards. Its upper end 
lies under the diaphragm near the body of the tenth 
dorsal vertebra and is covered by the edge of the left 
lung; the lower end lies beneath the tip of the eleventh 
rib just behind the mid-axillary line; the transverse 
diameter extends from the ninth to the eleventh ribs. 

Percussion and Palpation in Health. — Examina- 
tion can be made either in the dorsal, right lateral, or 
erect position, the two latter being the more conveni- 
ent. Palpation is negative in health. The upper 
third of the organ lies so deep that it is not accessible 
to percussion, and the relations of the rest of the 
spleen to air-containing parts are such that its limits 
are ordinarily determined by dullness rather than 
flatness. Moreover, the gaseous or solid contents 



— u8 — 

of the stomach or intestines may either mask or 
apparently increase the splenic dullness. It is, con- 
sequently, unsafe to rely implicitly on the results of a 
single examination. The area of splenic dullness is, 
then, in the erect posture, bounded by the scapular 
and mid-axillary lines between the ninth and eleventh 
ribs, and measures 7-8 centimeters in its long by 5-6 
centimeters in its short diameter. In the right lateral 
position the boundaries of the dullness are slightly 
different, and it may be useful to contrast the results 
of the two. But, of course, the erect position is often 
inadmissible. The organ descends somewhat with 
forced inspiration which diminishes its area of dullness 
by distending the portion of the left lung which over- 
lies its upper and posterior border. 

Percussion and Palpation in Disease.— Downward 
dislocation may be produced by intrathoracic disease 
which depresses the diaphragm, such as left pleural 
effusion or pneumothorax, and advanced emphysema; 
upward dislocation by great tympanites, ascites, or 
any cause which unduly elevates the diaphragm. In 
the condition known as " floating spleen/' the organ 
is generally, though not necessarily, enlarged, and its 
normal dullness disappears inasmuch as it sinks more 
or less into the abdominal cavity, and can there be 
felt. Apparent increase in the size has been already 
alluded to. In actual enlargement the shape of the 
normal dullness is closely preserved, but its size is in- 
creased in all directions. If the enlargement is mod- 



— II 9 — 

erate, the organ may be felt under, or in front of the 
rib margin only at the end of deep inspiration, 
provided that palpation is not rendered nugatory by 
hypersesthesia, tenderness, or abdominal distension. 
In great enlargement distinct fullness of the left side 
of the abdomen may be evident to the eye, while the 
non-resonant organ may be outlined by palpation, its 
notches felt, and its inspiratory descent determined. 
To distinguish positively between splenic tumor and 
enlargement, or tumor of the left kidney, it may be 
necessary to inflate the colon with air; if the tumor 
is of renal origin, it is then traversed by a belt of 
resonance. 

THE STOMACH. 

Scarcely any organ in the body varies so widely 
physiologically, as regards size and the character of 
its contents, as the stomach — a fact which renders the 
determination of its pathological conditions by the 
ordinary methods of physical exploration a matter of 
the greatest difficulty. Its proximity to the transverse 
colon is another pitfall. When the organ is moder- 
ately distended, and the person lies on the back, a 
small part of the anterior surface and the larger part 
of the greater curvature are in contact with the ab- 
dominal wall, the rest of it being covered by the left 
lobe of the liver and by the left lung. The pyloric 
portion lies in the right half of the epigastrium, barely 
reaching the right costal arch. The lower border 
crosses the epigastrium in a curved line nearly mid- 



120 

way between the ensiform cartilage and the navel. 
Percussion over this portion of the organ, which is 
more or less accessible to direct examination, is usu- 
ally tympanitic, of varying intensity and pitch. But 
the truth is that gastric percussion, even auscultatory 
percussion, is liable to so many sources of error as to 
be practically valueless for fine diagnostic purposes 
unless the stomach is artificially inflated. This is best 
done by passing the sound, and then pumping in air 
with a Davidson syringe. The outlines of the organ 
in the natural and distended conditions may then be 
contrasted, and the lower limit is often evident to the 
eye, in cases of great dilatation nearly as low as the 
pubes. If the abdominal wall is lax and the stomach 
dilated, gastric peristalsis may be distinctly seen. 
Swashing over the stomach is common enough during 
gastric digestion; to acquire any pathological signifi- 
cance it must be persistent, and present at a time 
when the organ should be empty or nearly so. Tu- 
mors seated in the anterior wall or the pyloric region 
may often be felt. 

THE PANCREAS. 

This organ lies so deep in the abdomen that it is 
practically never accessible to physical examination 
in health, and rarely in disease It extends trans- 
versely from the hilus of the spleen to the concavity 
of the duodenum, at the level of the first lumbar ver- 
tebra, overlies the aorta, and is covered by the stomach 



121 

and the left lobe of the liver. It therefore corre- 
sponds to a zone on the external surface, the lower 
margin of which is about an hand's-breadth above the 
umbilicus. The only affections of the organ which 
can well give rise to changes sufficiently gross to pro- 
duce local physical signs, are cancer and cysts. The 
former may, if it form a tumor over or bordering on 
the aorta, simulate aneurism; the latter may cause a 
more or less dull tympanitic bulging at the epigas- 
trium, somewhat similar to that which is seen in some 
cases of double pleural, or pericardial fluid accumula- 
tion. In an extreme case a pancreatic cyst may ex- 
tend below the navel. 



Mosquera's Food Products. 

MOSQUERA'S BEEF-MEAL 

Contains all the inorganic salts and stimulating principles of the extracts 
of meat, and, in addition, the nutritive principles which the extracts lack; 
all the albumen of meat juices, without their weakness; all the extracts 
of powdered meats, without their rancidity or insolubility; all the pep- 
tone of the peptonized meats, without their bitterness. 



MOSQUERA'S BEEF-MEAL 

Represents in actual nutritive value at least six times its weight of lean 
beef. It is perfectly palatable, and will be tolerated with ease by the 
most delicate stomachs. It admits of being administered in a variety of 
forms, thus avoiding monotony in the food. 

It may be given in any thick soup, condimented to suit the taste of 
the patient, or also mixed with biscuit powder, oatmeal porridge, and 
milk and sugar. Again, it may be mixed with chocolate, which makes 
a delicious beverage, or given in the form of a sandwich; and, finally, as 
a plain beef-tea, simply dissolving it in hot water, adding salt. 



MOSQUERA'S BEEF-CACAO 

Consists of equal parts of beef-meal, sugar, and a superior article of 
Dutch cacao. It does not require cooking, but may be mixed with warm 
milk exactly like ordinary chocolate, and so completely is the taste of the 
beef disguised that it can not be detected. Requiring, therefore, no 
previous preparation, it is most conveniently administered. 

We have decided to accept the sole agency of these products only 
after a very thorough investigation, and we will at all times be responsi- 
ble for their quality. 

To physicians interested, a pamphlet fully descriptive of the special 
advantages, uses, and methods of administration of these preparations, 
will be mailed, and prices furnished on request. 



PARKE, DAVIS & CO., 

Sole -<&.grexits, 
DETROIT, MICHIGAN, and NEW YORK, U.S.A. 



_ OF — 

GEORGE S. DAVIS, Publisher. 

THE THERAPEUTIC GAZETTE. 

A. Monthly Journal of Physiological and Clinical Therapeutics. 

EDITED BY 

IROiBIEIRT IMHE^IDIE SMITH, M. ID. 

SUBSCRIPTION PRICE, $2.00 PER YEAR. 

THE INDEX MEDICUS. 

A Monthly Classified Record of the Current Medical Literature of the World. 

COMPILED UNDER THE DIRECTION OF 

DR. JOHN S. BILLINGS, Surgeon U. S. A., 

and DR. ROBERT FLETCHER, M. R. C. S., En*. 

SUBSCRIPTION PRICE, $ 1 0.OO PER YEAR. 
THE AMERICAN LANCET. 

EDITED BY 

le^lettjs oousresroiR., nun. id. 

A MONTHLY JOURNAL DEVOTED TO REGULAR MEDICINE. 
SUBSCRIPTION PRICE, $2.00 PER YEAR. 

THE MEDICAL, AGE. 

EDITED BY 

IB. -W- ZE^^XiZMIIEIR,., -£L.. DMZ., JUL. H>. 

A Semi-Monthly Journal of Practical Medicine and Medical News. 

SUBSCRIPTION PRICE, $I.OO PER YEAR. 

THE WESTERN MEDICAL REPORTER. 

EDITED BY 

J-. IE. H^LEPEE, -A_. HUE.., JSJL. ID. 

A MONTHLY EPITOME OF MEDICAL PROGRESS. 

SUBSCRIPTION PRICE, $I.OO PER YEAR. 

THE DRUGGISTS' BULLETIN. 

EDITED BY 

IB. "W. IB-A-HLnVCIEJIR-, -A_. IMI., JUL. ID. 

A Monthly Exponent of Pharmaceutical Progress and News. 

SUBSCRIPTION PRICE, $ 1 .OO A YEAR. 



New subscribers taking more than one journal, and accompanying subscription 
by remittance, are entitled to the following special rates. 

GAZETTE and AGE, $2.50 ; GAZETTE, AGE and LANCET. $4.00 ; LANCET 
and AGE, $2.50 ; WESTERN MEDICAL REPORTER or BULLETIN with any of 
the above at 20 per cent, less than regular rates. 

Combined, these journals furnish a complete working library of current medi- 
cal literature. All the medical news, and full reports of medical progress. 



GEO. S. DAYIS, Publisher, Detroit, Mich. 



IN EXPLANATION 

OF 

The Physicians' Leisure Library. 

We have made a new departure in the publication of medical books. As you 
no doubt know, many of the large treatises published, which sell for four or five or 
more dollars, contain much irrelevant matter of no practical value to the physi- 
cian, and their high price makes it often impossible for the average practitioner to 
purchase anything like a complete library. 

Believing that short practical treatises, prepared by well known authors, con- 
taining the gist of what they had to say regarding the treatment of diseases com- 
monly met with, and of which they had made a special study, sold at a small price, 
would be welcomed by the majority of the profession, we have arranged for the 
publication of such a series, calling it Tlae Physicians' Leisure Library. 

This series has met with the approval and appreciation of the medical profes- 
sion, and we shall continue to issue in it books by eminent authors of this country 
and Europe, covering the best modern treatment of prevalent diseases. 

The series will certainly afford practitioners and students an opportunity 
never before presented for obtaining a working library of books by the best authors 
at a price which places them within the reach of all . The books are amply illus- 
trated, and issued in attractive form. 

They may be had bound, either in durable paper covers at 25 Cts. per copy, 
or in cloth at 50 Cts. per copy. Complete series of 12 books in sets as announced, 
at $2.50, in paper, or cloth at $5.00, postage prepaid. See complete list. 



PHYSICIANS' LEISURE LIBRARY 



PRICEs PAPER, 25 CT?. PER COPY, $2.50 PER SET; CLOTH, 50 CTS, PER COPY, 
$5.00 PER SET. 



SERIES I. 



Inhalersi Inhalations and Inhalants. 
By Beverley Robinson, M. D. 

The Use of Electricity in the Removal of 
Superfluous Hair and the Treatment of 
Various Facial Blemishes. 
By Geo. Henry Fox, M. D. 

New Medications, Vol. \, 

By Dujardin-Beaumetz, M. D. 

New Medicationsi Vol. It. 

By Dujardm-Beaumetz, M. D. 

The Modern Treatment of Ear Diseases. 
By Samuel Sexton, M. D. 

The Modern Treatment of Eczema. 
By Henry G. Piffard, M. D. 



Antiseptic Midwifery. 

By Henry J. Garrigues, M. D. 

On the Determination of the Necessity for 
Wearing Glasses. 

By D. B. St. John Roosa, M. D. 
The Physiological, Pathological and Ther- 
apeutic Effects of Compressed Air. 
By Andrew H. Smith, M. D. 
GranularLids and ContagiousOphthalmla. 

By W. F. Mittendorf, M. D> 
Practical Bacteriology. 

Bv Thomas E. Satterthwaite, M. D. 
Pregnancy, Parturition, the Puerperal 
State and their Complications. 
By Paul F. Munde\ M. D. 



SERIES II. 



The Diagnosis and Treatmentof Haemor- 
rhoids. 

By Chas. B. Kelsey, M. D. 
Diseases of the Heart, Vol. I. 

By Dujardin-Beaumetz, M. D. 
Diceases of the Heart, Vol. II, 

By Dujardin-Beaumeiz, M. D. 

The Modern Treatment of Diarrhoea and 
Dysentery. 

By A. B. Palmer, M. D. 
Intestinal Diseases of Children, Vol. I. 

By A. Jacobi, M. D. 
Intestinal Diseases of Children, Vol. II. 

toy A. Jacobi, M. . 



The Modern Treatment of Headaches, 
By Allan McLane Hamilton, M. D. 

The Modern Treatment of Pleurisy and 
Pneumonia. 

By G. M. Garland, M. D. 
Diseases of the Male Urethra. 

By Fessenden N. Otis, M. D. 
The Disorders of Menstruation. 

By Edward W. Jenks, M. D. 
The Infectious Diseases, Vol. I, 

By Karl Liebermeister. 

The Infectious Diseases, Vol. II. 
fey Karl Liebermeister. 



SERIES III. 



Abdominal Surgery. 

By Hal C. Wyman, M. D. 

Diseases of the Liver 

By JLujardin-Beaumetz, M. D. 

Hysteria and Epilepsy. 

By J. Leonard Corning, M. D. 

Diseases of the Kidney. 

By Dujardin-Beaumetz, M. D. 

The Theory and Practice o? the Ophthal- 
moscope. 

By J. Herbert Claiborne, Jr., M. D. 

Modern Treatmentof Bright's Disease. 
By Alfred L. Loomis, M. D. 



Clinical Lectures on Certain Diseases or 
Nervous System. 

By Prof. J. M. Charcot, M. D. 
The Radical Cure of Hernia. 

By Henry O. Marcy, A M, M. D., 
L. L D. 
Spinal Irritation. 

By William A. Hammond, M. D. 
Dyspepsia. 

By Frank Woodbury, M. D. 
The Treatment of the Morphia Habit. 

By Erlenmeyer. 
The Etiology, Diagnosis and Therapy of 
Tuberculosis 

By Prof. H. von Ziemssen. 



SERIES IY. 



Nervous Syphilis. 

By H. C. Wood, M. 



D. 



Education and Culture as correlated to 
the Health and Diseases of Women. 
By A. J. C. Skene, M. D. 

Diabetes. 

By A. H. Smith, M D. 

A Treatise on Fractures. 

By At man d Despres, M. D. 

Some Majorand Minor Fallacies concern- 
ing Syphilis. 

By E. L. Keyes, M. D. 
Hypodermic Medication. 

By Bourneville and Bricon. 



Practical Points in the Management of 
Diseases of Children. 
By I. N. Love, M. D. 

Neuralgia. 

By E. P. Hurd, M. D. 

Rheumatism and Gout. 

By F. Le Koy Satterlee, M. D. 
Electricity, Its Application in Med'cme. 

By Wellington Adams, M.D. [Vol.1] 
Electricity, Its Application In Medicne, 

By Wei i-gton Adams, M.D. [Vol.11] 
Auscultation and Percussion. 

By Frederick C. Shattuck, M. D. 



SERIES IT. 



Taking Cold. 

By F. W. Bosworth, M. D. 

Practical Notes on Urinary Analy- 
sis. 

By William B. Canfield, M. D. 

Practical Intestinal Surgery. Vol. I. 
Practical Intestinal Surgery. Vol.11. 

By F. B. Robinson, M. D. 
Lectures on Tumors. 

By John B. Hamilton, M. D., LL. D. 

Pulmonary Consumption, a Ner- 
vous Disease. 

By Thomas J . Mays, M . D . 

Lessons in the Diagnosis and 
Treatment of Eye Diseases. 

By Casey A. Wood, M. D. 



Diseases of the Bladder and Pros- 
tate. 

By Hal C. Wyman, M. D. 

Artificial Anaesthesia and Anaes- 
thetics. 

By DeForest Willard, M. D., and Dr. 
Lewis H. Adler, Jr. 

Cancer. 

By Daniel Lewis, M. D. 

The Modern Treatment of Hip DIs* 
ease. 

By Charles F. Stillman, M. D. 

Insomnia and Hypnotics. 

By Germain See. 

Translated by E. P. Hurd, M. D. 



BOOKS BY LEADING AUTHORS. 



SEXUAL IMPOTENCE IN MALE AND FEMALE $3.00 

Bv Wm. A. Hammond, M. D. 
PHYSICIANS' PERFECT VISITING LIST 1.50 

Bv G, Archie Stockwell, M. D. 
A NEW TREATMENT OF CHRONIC METRITIS 50 

By Dr. Georges Apostoli 
CLINICAL THERAPEUTICS 25 

Bv Dujardin-Beaumetz, M. D. 
MICROSCOPICAL DIAGNOSIS 4.00 

By Prof. Chas. H. Stowell, M. S. 
PALATABLE PRESCRIBING 3.00 

By B. W. Palmer, A. M , M. D. 
UNTOWARD EFFECTS OF DRUGS 2.00 

By L. Lewin, M. D. 
SANITARY SUGGESTIONS (Paper) 25 

Bv B W. Palmer, M D. 
SELECT EXTRA-TROPICAL PLANTS 3.00 

By Baron Ferd. von Mueller, 
TABLES FOR DOCTOR AND DRUGGIST 2.00 

By Eli H. Long, M. D. 



GEORGE S. DAYIS, Publisher, 

IE 3 O. Boz ^T70 IDetxoit, ^Cioli.. 



